Organization
KIDS-DOC-ON-WHEELS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LYNETTE R WILSON-PHILLIPS MD (BOARD OF DIRECTORS)
(404) 574-2512
Entity
Organization
Contact information
Practice address
4112 E PONCE DE LEON AVE # 2, CLARKSTON, GA 30021-8106
(404) 574-2512
(404) 296-7211
Mailing address
4112 E PONCE DE LEON AVE # 2, CLARKSTON, GA 30021-8106
(404) 574-2512
(404) 296-7211
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003193946A
—
GA
Enumeration date
07/11/2017
Last updated
12/14/2017
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