Provider Demographics
NPI:1972015097
Name:KIDZCARE PEDIATRICS, PC
Entity Type:Organization
Organization Name:KIDZCARE PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANTAE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-483-7337
Mailing Address - Street 1:5617 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1423
Mailing Address - Country:US
Mailing Address - Phone:910-483-7337
Mailing Address - Fax:910-483-0648
Practice Address - Street 1:112 MEDICAL VILLAGE DR STE D
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-1665
Practice Address - Country:US
Practice Address - Phone:910-665-1437
Practice Address - Fax:910-665-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty