=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689736118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VOA AMBULATORY SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 12/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3527 B NORTH VALDOSTA ROAD
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-253-9336
-----------------------------------------------------
Fax | 229-253-9345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3527B N VALDOSTA RD
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-253-9336
-----------------------------------------------------
Fax | 229-253-9345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JOHN KENDRICK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 229-253-9336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 092165
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------