Healthcare Provider Details

I. General information

NPI: 1316249246
Provider Name (Legal Business Name): IDLEWOOD MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2157 IDLEWOOD RD STE B
TUCKER GA
30084-4832
US

IV. Provider business mailing address

2157 IDLEWOOD RD STE B
TUCKER GA
30084-4832
US

V. Phone/Fax

Practice location:
  • Phone: 305-388-4383
  • Fax: 305-388-4380
Mailing address:
  • Phone: 305-388-4383
  • Fax: 305-388-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AIDA ROSA DE LA VEGA
Title or Position: CEO
Credential:
Phone: 305-388-4383