MEDICARE: VICO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1184059198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICO LLC

Provider Business Mailing Address
First Line	:	2766 ELKMONT RDG SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-9434
Country	:	US
Telephone Number	:	404-532-9926
Fax Number	:	866-862-9942

Provider Business Practice Location Address
First Line	:	2766 ELKMONT RDG SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-9434
Country	:	US
Telephone Number	:	404-532-9926
Fax Number	:	866-862-9942

Authorized Official
Title or Position	:	OWNER
Name	:	VIOLETTA ARDOIN
Credential	:
Telephone Number	:	404-532-9926

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	09/09/2013

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