=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982821971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARL VISON VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 BLUEBERRY FARM ROAD
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 BLUEBERRY FARM ROAD
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ICU STAFF NURSE
-----------------------------------------------------
Name | MR. VENOID VANN IRVIN
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 478-277-2724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | RN085341
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------