Healthcare Provider Details

I. General information

NPI: 1437332699
Provider Name (Legal Business Name): SANTA ROSA CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E WALNUT AVE SUITE #4
DALTON GA
30721-4196
US

IV. Provider business mailing address

1200 E WALNUT AVE SUITE #4
DALTON GA
30721-4196
US

V. Phone/Fax

Practice location:
  • Phone: 706-259-5579
  • Fax: 706-259-6558
Mailing address:
  • Phone: 706-259-5579
  • Fax: 706-259-6558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number053528
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number050406
License Number StateGA

VIII. Authorized Official

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