Provider Demographics
NPI:1437494523
Name:CANDID MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:CANDID MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BODO
Authorized Official - Middle Name:
Authorized Official - Last Name:PYKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-994-1250
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3027
Mailing Address - Country:US
Mailing Address - Phone:631-930-5215
Mailing Address - Fax:
Practice Address - Street 1:6525 PROFESSIONAL PL
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:770-994-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty