1407091887 NPI number — LAGRANGE CARDIOVASCULAR CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407091887 NPI number — LAGRANGE CARDIOVASCULAR CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGRANGE CARDIOVASCULAR CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407091887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MEDICAL DR
Provider Second Line Business Mailing Address:
SUITE 506
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30240-4144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-883-7341
Provider Business Mailing Address Fax Number:
706-883-7572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 506
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-4144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-883-7341
Provider Business Practice Location Address Fax Number:
706-883-7572
Provider Enumeration Date:
12/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WODI
Authorized Official First Name:
LINUS
Authorized Official Middle Name:
ADAH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-883-7341

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  061683 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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