1205078979 NPI number — VIDALIA FAMILY HEALTH CLINIC LLC

Table of content: (NPI 1205078979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205078979 NPI number — VIDALIA FAMILY HEALTH CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIDALIA FAMILY HEALTH CLINIC 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:
6
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:
1205078979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1811 MANNING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30474-8921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-7674
Provider Business Mailing Address Fax Number:
912-538-8443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 MANNING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474-8921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-537-7674
Provider Business Practice Location Address Fax Number:
912-538-8443
Provider Enumeration Date:
03/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FERRARI
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
912-537-7476

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  GA034829 , 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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