Provider Demographics
NPI:1487742532
Name:WESTCARE VILLA RICA PEDIATRICS
Entity type:Organization
Organization Name:WESTCARE VILLA RICA PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-832-2005
Mailing Address - Street 1:626 DALLAS HWY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1209
Mailing Address - Country:US
Mailing Address - Phone:770-459-9378
Mailing Address - Fax:770-459-8613
Practice Address - Street 1:626 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1209
Practice Address - Country:US
Practice Address - Phone:770-459-9378
Practice Address - Fax:770-459-8613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA203686572AOtherMEDICAID PAYEE NUMBER
GA=========OtherTAX ID