Provider Demographics
NPI:1669756292
Name:STAY WELL PEDIATRICS LLC
Entity type:Organization
Organization Name:STAY WELL PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-248-2350
Mailing Address - Street 1:5139 JIMMY CARTER BLVD
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1680
Mailing Address - Country:US
Mailing Address - Phone:678-248-2350
Mailing Address - Fax:678-404-8435
Practice Address - Street 1:5139 JIMMY CARTER BLVD
Practice Address - Street 2:SUITE # 205
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1680
Practice Address - Country:US
Practice Address - Phone:678-248-2350
Practice Address - Fax:678-404-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060096261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA328093387AMedicaid