Provider Demographics
NPI:1407094212
Name:SANTA ROSA CLINIC, PA
Entity Type:Organization
Organization Name:SANTA ROSA CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:MALPARTIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-259-5579
Mailing Address - Street 1:355 RICHARDSON RD SE STE 6
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3681
Mailing Address - Country:US
Mailing Address - Phone:706-625-2237
Mailing Address - Fax:706-625-2239
Practice Address - Street 1:355 RICHARDSON RD SE STE 6
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3681
Practice Address - Country:US
Practice Address - Phone:706-625-2237
Practice Address - Fax:706-625-2239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA ROSA CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50406261QA0600X
GA53528261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA342515362AMedicaid
GA849865610-AMedicaid
GA11BDXHGMedicare Oscar/Certification
GA849865610-AMedicaid