Basic Information
| Provider Information | |||||||||
| NPI: | 1144608316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7963 HARMONY RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300581513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783584639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | CREWS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 4043216111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | MSW005664 | GA | Y | Hospitals | Special Hospital |
No ID Information.