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NPI Code Detail

MEDICARE: SOUTHEAST ATLANTA VASCULAR CARE, LLC

MEDICARE: SOUTHEAST ATLANTA VASCULAR CARE, 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
1261QA1903XAmbulatory Surgical Clinic/Center

General Provider Information

NPI Number : 1689195786
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHEAST ATLANTA VASCULAR CARE, LLC
Provider Business Mailing Address
First Line : 9140 CORSEA DEL FONTANA WAY
Second Line :
City : NAPLES
State : FL
Zip : 34109-4397
Country : US
Telephone Number : 239-597-2010
Fax Number : 239-597-2313
Provider Business Practice Location Address
First Line : 5461 HILLANDALE DR STE 210
Second Line :
City : LITHONIA
State : GA
Zip : 30058-4842
Country : US
Telephone Number : 770-981-8477
Fax Number : 770-981-8477
Authorized Official
Title or Position : OFFICER AND AUTHORIZED OFFICIAL
Name : JENNIFER BOYD BALDOCK
Credential :
Telephone Number : 615-234-5954
Provider Enumeration Date : 06/29/2017
Last Update Date : 02/05/2026

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Directions to “SOUTHEAST ATLANTA VASCULAR CARE, LLC ” Practice Location

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