Provider Demographics
NPI:1689195786
Name:SOUTHEAST ATLANTA VASCULAR CARE, LLC
Entity Type:Organization
Organization Name:SOUTHEAST ATLANTA VASCULAR CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-597-2010
Mailing Address - Street 1:9140 CORSEA DEL FONTANA WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-4397
Mailing Address - Country:US
Mailing Address - Phone:239-597-2010
Mailing Address - Fax:239-597-2313
Practice Address - Street 1:5461 HILLANDALE DR STE 210
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4842
Practice Address - Country:US
Practice Address - Phone:770-981-8477
Practice Address - Fax:770-981-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical