1215112685 NPI number — VASCULAR ACCESS CENTER CENTER OF SOUTH ATLANTA, 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 1215112685 NPI number — VASCULAR ACCESS CENTER CENTER OF SOUTH ATLANTA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VASCULAR ACCESS CENTER CENTER OF SOUTH ATLANTA, 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:
1215112685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-9089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-507-4042
Provider Business Mailing Address Fax Number:
770-507-4071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-9089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-382-3680
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARKINSON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
215-382-3680

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X , 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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