Basic Information
| Provider Information | |||||||||
| NPI: | 1922119163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATL VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4657 BEXLEY DR | ||||||||
| Address2: | |||||||||
| City: | STONE MOUNTAIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300835560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708081598 | ||||||||
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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: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | ANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4043216111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | RN099782 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.