Healthcare Provider Details

I. General information

NPI: 1689195786
Provider Name (Legal Business Name): SOUTHEAST ATLANTA VASCULAR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 HILLANDALE DR STE 210
LITHONIA GA
30058-4842
US

IV. Provider business mailing address

9140 CORSEA DEL FONTANA WAY
NAPLES FL
34109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 770-981-8477
  • Fax: 770-981-8477
Mailing address:
  • Phone: 239-597-2010
  • Fax: 239-597-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA MCNAMARA
Title or Position: EVP
Credential:
Phone: 239-597-2010