Provider Demographics
NPI:1184201022
Name:SOUTHERN VEIN CARE
Entity Type:Organization
Organization Name:SOUTHERN VEIN CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARNET
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:CRADDOCK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-683-8346
Mailing Address - Street 1:2959 SHARPSBURG MCCULLUM RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2297
Mailing Address - Country:US
Mailing Address - Phone:770-683-8346
Mailing Address - Fax:770-916-7642
Practice Address - Street 1:2959 SHARPSBURG MCCULLUM RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2297
Practice Address - Country:US
Practice Address - Phone:770-683-8346
Practice Address - Fax:770-916-7642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty