Provider Demographics
NPI:1912088790
Name:CAPITAL CITY CHILDREN AND ADOLESCENT CLINIC
Entity Type:Organization
Organization Name:CAPITAL CITY CHILDREN AND ADOLESCENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-362-7476
Mailing Address - Street 1:2679 CRANE RIDGE DR
Mailing Address - Street 2:STE F
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4997
Mailing Address - Country:US
Mailing Address - Phone:601-362-7476
Mailing Address - Fax:
Practice Address - Street 1:2679 CRANE RIDGE DR
Practice Address - Street 2:STE F
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4997
Practice Address - Country:US
Practice Address - Phone:601-362-7476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016857Medicaid