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General NPI Number Information
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NPI Number | 1114733250
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Entity Type | Organization
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Legal Business Name | VIDALIA FAMILY CARE LLC
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 1702 MEADOWS LN
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City | VIDALIA
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State | GA
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Zip | 30474-7219
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Country | US
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Telephone | 912-805-2198
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Fax | 912-805-2997
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Provider Business Mailing Address
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Address Line | PO BOX 645
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City | VIDALIA
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State | GA
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Zip | 30475-0645
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Country | US
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Telephone | 912-293-3308
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JOHN BURTON DERRICK
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Credential | PA-C
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Telephone | 912-293-3308
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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