Provider Demographics
NPI:1811241417
Name:VIBRANT KIDS PEDIATRICS, LLC
Entity type:Organization
Organization Name:VIBRANT KIDS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:BURNETT
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-423-5560
Mailing Address - Street 1:87 TAPESTRY LN
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5649
Mailing Address - Country:US
Mailing Address - Phone:678-423-5560
Mailing Address - Fax:678-423-5563
Practice Address - Street 1:10 MARKET SQUARE WAY STE 100
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6078
Practice Address - Country:US
Practice Address - Phone:678-423-5560
Practice Address - Fax:678-423-5563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061061261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center