Healthcare Provider Details

I. General information

NPI: 1285401901
Provider Name (Legal Business Name): LA CLINIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 N THORNTON AVE
DALTON GA
30720-3605
US

IV. Provider business mailing address

1240 N THORNTON AVE
DALTON GA
30720-3605
US

V. Phone/Fax

Practice location:
  • Phone: 706-229-9313
  • Fax: 706-229-9388
Mailing address:
  • Phone: 706-229-9313
  • Fax: 706-229-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMSES VEGA-CASASNOVAS
Title or Position: OWNER
Credential: MD
Phone: 336-688-6240