Imagix Legacy Pediatrics LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

IMAGIX LEGACY PEDIATRICS LLC

Practice address

3903 Jiles Rd NW
210
Kennesaw, GA 30144-4612

Phone

(770) 590-9050

NPI assigned

Nov 17, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Crystal Chouinard

Title

Credentialing Specialist

Phone

(941) 955-3150

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1447718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447718400000",
    "number": "1295109015",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3903 JILES RD NW",
            "address_2": "210",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301444612",
            "telephone_number": "770-590-9050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3903 JILES RD NW",
            "address_2": "210",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301444612",
            "telephone_number": "770-590-9050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMAGIX LEGACY PEDIATRICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-17",
        "last_updated": "2015-11-17",
        "status": "A",
        "authorized_official_last_name": "CHOUINARD",
        "authorized_official_first_name": "CRYSTAL",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "941-955-3150"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 17, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.