Provider Demographics
NPI:1588425953
Name:PEDIATRIC CLINIC LLC
Entity type:Organization
Organization Name:PEDIATRIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:PASCHAL
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-749-8121
Mailing Address - Street 1:2401 VILLAGE PROFESSIONAL DR S
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-4702
Mailing Address - Country:US
Mailing Address - Phone:334-749-8121
Mailing Address - Fax:334-749-6166
Practice Address - Street 1:2375 CHAMPIONS BLVD STE 3
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-6471
Practice Address - Country:US
Practice Address - Phone:334-749-8121
Practice Address - Fax:334-749-6166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty