Provider Demographics
NPI:1942974167
Name:VIDALIA IMMEDIATE & PRIMARY CARE LLC
Entity type:Organization
Organization Name:VIDALIA IMMEDIATE & PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BECKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-293-2869
Mailing Address - Street 1:PO BOX 2324
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-2324
Mailing Address - Country:US
Mailing Address - Phone:912-805-2273
Mailing Address - Fax:
Practice Address - Street 1:122 ALICE COLEMAN DRIVE
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-805-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care