Healthcare Provider Details

I. General information

NPI: 1578183737
Provider Name (Legal Business Name): VEDA LARA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 LAUREL PARK CIR NE
ATLANTA GA
30329-3217
US

IV. Provider business mailing address

1530 LAUREL PARK CIR NE
ATLANTA GA
30329-3217
US

V. Phone/Fax

Practice location:
  • Phone: 404-447-9803
  • Fax:
Mailing address:
  • Phone: 404-447-9803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN C DUDLEY
Title or Position: OWNER
Credential: MD
Phone: 404-447-9803