Provider Demographics
NPI:1538679576
Name:VA
Entity Type:Organization
Organization Name:VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:352-376-1611
Mailing Address - Street 1:1601 S.W. ARCHER ROAD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1197
Mailing Address - Country:US
Mailing Address - Phone:352-376-1611
Mailing Address - Fax:
Practice Address - Street 1:1601 S.W. ARCHER ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1197
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5148178164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty