Provider Demographics
NPI:1366891947
Name:VALDOSTA HEALTHCARE CLUB
Entity type:Organization
Organization Name:VALDOSTA HEALTHCARE CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-506-5559
Mailing Address - Street 1:4370 KINGS WAY STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6905
Mailing Address - Country:US
Mailing Address - Phone:229-506-5559
Mailing Address - Fax:
Practice Address - Street 1:4370 KINGS WAY STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6905
Practice Address - Country:US
Practice Address - Phone:229-506-5559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty