Provider Demographics
NPI:1821116781
Name:WEST GEORGIA CENTER FOR DIABETES AND ENDOCRINOLOGY
Entity Type:Organization
Organization Name:WEST GEORGIA CENTER FOR DIABETES AND ENDOCRINOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:VAVRIK
Authorized Official - Suffix:
Authorized Official - Credentials:M,D
Authorized Official - Phone:678-796-0681
Mailing Address - Street 1:410 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3922
Mailing Address - Country:US
Mailing Address - Phone:678-796-0681
Mailing Address - Fax:770-836-8477
Practice Address - Street 1:410 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3922
Practice Address - Country:US
Practice Address - Phone:678-796-0681
Practice Address - Fax:770-836-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty