Provider Demographics
NPI:1679529051
Name:KIDZCARE PEDIATRICS, PC
Entity type:Organization
Organization Name:KIDZCARE PEDIATRICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANTAE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-483-7337
Mailing Address - Street 1:PO BOX 9219
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9082
Mailing Address - Country:US
Mailing Address - Phone:910-483-7337
Mailing Address - Fax:910-483-0648
Practice Address - Street 1:3436 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348
Practice Address - Country:US
Practice Address - Phone:910-426-7337
Practice Address - Fax:910-424-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900115Medicaid
NC016VROtherBCBS GROUP# HOPEMILLS
NC5900116,5908525Medicaid
NC5900116Medicaid
NC5950741,5914484Medicaid
NC016VPOtherBCBS GROUP# FOR NORTHSIDE