Healthcare Provider Details

I. General information

NPI: 1922119163
Provider Name (Legal Business Name): ATL VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

4657 BEXLEY DR
STONE MOUNTAIN GA
30083-5560
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 770-808-1598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRN099782
License Number StateGA

VIII. Authorized Official

Name: MS. ANNA JOHNSON
Title or Position: NURSE MANAGER
Credential:
Phone: 404-321-6111