Provider Demographics
NPI:1750420428
Name:SHORE FUN PEDIATRICS
Entity type:Organization
Organization Name:SHORE FUN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRUCIE
Authorized Official - Middle Name:JANELLE
Authorized Official - Last Name:SPIVEY-COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-754-7075
Mailing Address - Street 1:14 DOCTORS CIR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4097
Mailing Address - Country:US
Mailing Address - Phone:910-754-7075
Mailing Address - Fax:910-754-2158
Practice Address - Street 1:14 DOCTORS CIR
Practice Address - Street 2:SUITE 3
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4097
Practice Address - Country:US
Practice Address - Phone:910-754-7075
Practice Address - Fax:910-754-2158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty