Provider Demographics
NPI:1013623263
Name:HOMETOWN PEDIATRICS LLC
Entity Type:Organization
Organization Name:HOMETOWN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:PULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:850-688-0943
Mailing Address - Street 1:108 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:GA
Mailing Address - Zip Code:31092-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 N 4TH ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:GA
Practice Address - Zip Code:31092-1115
Practice Address - Country:US
Practice Address - Phone:229-231-5008
Practice Address - Fax:229-231-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1932748894Medicaid