Provider Demographics
NPI:1811391691
Name:ATLANTA VA MEDICAL CENTER
Entity Type:Organization
Organization Name:ATLANTA VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:VETA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-602-4131
Mailing Address - Street 1:5416 ORANGE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2649
Mailing Address - Country:US
Mailing Address - Phone:863-602-4131
Mailing Address - Fax:863-709-1520
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-417-1540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA202364313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility