Provider Demographics
NPI:1962676502
Name:SENSATIONAL KIDS PEDIATRIC REHABILITATION & COUNSELING, INC.
Entity Type:Organization
Organization Name:SENSATIONAL KIDS PEDIATRIC REHABILITATION & COUNSELING, INC.
Other - Org Name:SENSATIONAL KIDS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-364-3470
Mailing Address - Street 1:3580 RIVER WATCH PKWY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3682
Mailing Address - Country:US
Mailing Address - Phone:706-364-3470
Mailing Address - Fax:706-364-3470
Practice Address - Street 1:3580 RIVER WATCH PKWY
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-3682
Practice Address - Country:US
Practice Address - Phone:706-364-3470
Practice Address - Fax:706-364-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA689380396AMedicaid