Provider Demographics
NPI:1104141837
Name:EXCELLENT PEDIATRICS
Entity type:Organization
Organization Name:EXCELLENT PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-807-2241
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-0747
Mailing Address - Country:US
Mailing Address - Phone:678-807-2230
Mailing Address - Fax:
Practice Address - Street 1:333 ALCOVY ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2180
Practice Address - Country:US
Practice Address - Phone:678-807-2230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055771261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care