Healthcare Provider Details

I. General information

NPI: 1407094212
Provider Name (Legal Business Name): SANTA ROSA CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 RICHARDSON RD SE STE 6
CALHOUN GA
30701-3681
US

IV. Provider business mailing address

355 RICHARDSON RD SE STE 6
CALHOUN GA
30701-3681
US

V. Phone/Fax

Practice location:
  • Phone: 706-625-2237
  • Fax: 706-625-2239
Mailing address:
  • Phone: 706-625-2237
  • Fax: 706-625-2239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number53528
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number50406
License Number StateGA

VIII. Authorized Official

Name: DR. JUAN CARLOS MALPARTIDA
Title or Position: OWNER
Credential: MD
Phone: 706-259-5579