Basic Information
| Provider Information | |||||||||
| NPI: | 1558548693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF VETERANS AFFAIR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3492 SKYLAND RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300528783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
| FaxNumber: | 4047287746 | ||||||||
| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
| FaxNumber: | 4047287746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRUZ-LAPORTE | ||||||||
| AuthorizedOfficialFirstName: | ROSULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STAFF NURSE | ||||||||
| AuthorizedOfficialTelephone: | 4043216111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BSN,RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 011861 | PR | Y | Hospitals | Military Hospital |
No ID Information.