Provider Demographics
NPI:1396145058
Name:WALTON CHILDREN'S CLINIC
Entity type:Organization
Organization Name:WALTON CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EBBA
Authorized Official - Middle Name:K
Authorized Official - Last Name:EBBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-207-5437
Mailing Address - Street 1:98 TARA COMMONS DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8031
Mailing Address - Country:US
Mailing Address - Phone:770-207-5437
Mailing Address - Fax:770-207-7263
Practice Address - Street 1:98 TARA COMMONS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8031
Practice Address - Country:US
Practice Address - Phone:770-207-5437
Practice Address - Fax:770-207-7263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-01
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036724208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty