Provider Demographics
NPI:1093049520
Name:VA MEDICAL CENTER
Entity Type:Organization
Organization Name:VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/EMERGENCY NURSING
Authorized Official - Prefix:
Authorized Official - First Name:VETA
Authorized Official - Middle Name:SHANTAYE
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-602-4131
Mailing Address - Street 1:5416 ORANGE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2649
Mailing Address - Country:US
Mailing Address - Phone:863-602-4131
Mailing Address - Fax:
Practice Address - Street 1:5416 ORANGE VALLEY DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2649
Practice Address - Country:US
Practice Address - Phone:863-602-4131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9257726251J00000X
GARN202364286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No286500000XHospitalsMilitary Hospital