1861439614 NPI number — THE VASCULAR CLINIC LLC

Table of content: (NPI 1861439614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861439614 NPI number — THE VASCULAR CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE VASCULAR 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:
1861439614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 GROSS CRESCENT CIR
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
FT OGLETHORPE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30742-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-858-0204
Provider Business Mailing Address Fax Number:
706-858-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 GROSS CRESCENT CIR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
FT OGLETHORPE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30742-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-858-0204
Provider Business Practice Location Address Fax Number:
706-858-0225
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAAKA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-858-0204

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4176994 . This is a "TENNESSE BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 143447302A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3734225 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com