Healthcare Provider Details

I. General information

NPI: 1265477863
Provider Name (Legal Business Name): ATLANTA VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

6 FAIRFIELD DR
ELLENWOOD GA
30294-2810
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 678-833-5759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number018134
License Number StatePR

VIII. Authorized Official

Name: MS. YLBA M HOOKER
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 404-321-6111