Healthcare Provider Details

I. General information

NPI: 1497953012
Provider Name (Legal Business Name): VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 POST OAK DR APT F
CLARKSTON GA
30021-3145
US

IV. Provider business mailing address

PO BOX 33622
DECATUR GA
30033-0622
US

V. Phone/Fax

Practice location:
  • Phone: 404-808-3229
  • Fax:
Mailing address:
  • Phone: 404-808-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberLPN074690
License Number StateGA

VIII. Authorized Official

Name: MS. LEA MICHELLE WALKER
Title or Position: LPN
Credential:
Phone: 404-808-3229