Provider Demographics
NPI:1487634648
Name:VINA HEALTH CARE CLINIC CORPORATION
Entity Type:Organization
Organization Name:VINA HEALTH CARE CLINIC CORPORATION
Other - Org Name:VINA HEALTH CARE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-366-8822
Mailing Address - Street 1:4487 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-4316
Mailing Address - Country:US
Mailing Address - Phone:404-366-8822
Mailing Address - Fax:404-366-8824
Practice Address - Street 1:4487 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-4316
Practice Address - Country:US
Practice Address - Phone:404-366-8822
Practice Address - Fax:404-366-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-21
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040894208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000766884AMedicaid
GA01BDJTWMedicare ID - Type UnspecifiedMEDICARE PART B
GA000766884AMedicaid