Provider Demographics
NPI:1982858767
Name:SOUTHERN PEDIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:SOUTHERN PEDIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-241-0059
Mailing Address - Street 1:406 M NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-241-0059
Mailing Address - Fax:229-241-2088
Practice Address - Street 1:406 M NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-241-0059
Practice Address - Fax:229-241-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty