1437484185 NPI number — VCP ATLANTA, LLC

Table of content: (NPI 1437484185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437484185 NPI number — VCP ATLANTA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VCP 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:
VEIN CARE PAVILION OF ATLANTA
Provider Other Organization Name Type Code:
3
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:
1437484185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4350 TOWNE CENTRE DR
Provider Second Line Business Mailing Address:
STE 2000
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809-3301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-854-3333
Provider Business Mailing Address Fax Number:
706-396-0615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3390 PEACHTREE RD NE
Provider Second Line Business Practice Location Address:
STE 425
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30326-1157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-846-2460
Provider Business Practice Location Address Fax Number:
404-846-2440
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SOLE MEMBER/PRESIDENT
Authorized Official Telephone Number:
706-854-2138

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  033061 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 48566 , 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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