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General NPI Number Information
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NPI Number | 1922346709
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Entity Type | Organization
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Legal Business Name | VIDRO INDUSTRIES, LLC
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Dates
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Enumeration Date | 01/29/2013
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Last Update Date | 01/29/2013
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Provider Practice Location Address
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Address Line | 20 HERRELL RD
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City | VILLA RICA
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State | GA
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Zip | 30180-5527
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Country | US
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Telephone | 770-456-3929
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1149
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City | VILLA RICA
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State | GA
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Zip | 30180-6149
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Country | US
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Telephone | 404-858-1063
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. RICHARD GLASS
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Credential | M,D.
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Telephone | 404-858-1063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 62989
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License Number State | GA
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