Basic Information
| Provider Information | |||||||||
| NPI: | 1811391691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5416 ORANGE VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636024131 | ||||||||
| FaxNumber: | 8637091520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
| FaxNumber: | 4044171540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 10/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | KEYS | ||||||||
| AuthorizedOfficialFirstName: | VETA | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 8636024131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 202364 | GA | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.