Provider Demographics
NPI:1437332699
Name:SANTA ROSA CLINIC, PA
Entity Type:Organization
Organization Name:SANTA ROSA CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
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 1:1200 E WALNUT AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-4196
Mailing Address - Country:US
Mailing Address - Phone:706-259-5579
Mailing Address - Fax:706-259-6558
Practice Address - Street 1:1200 E WALNUT AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4196
Practice Address - Country:US
Practice Address - Phone:706-259-5579
Practice Address - Fax:706-259-6558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050406261QA0600X
GA053528261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034256FMedicaid
GA342515362AMedicaid
GA849865610-AMedicaid
GA849865610-AMedicaid