Provider Demographics
NPI:1922346709
Name:VIDRO INDUSTRIES, LLC
Entity Type:Organization
Organization Name:VIDRO INDUSTRIES, LLC
Other - Org Name:VIDRO HEALTH INDUSTRIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:M,D
Authorized Official - Phone:404-858-1063
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6149
Mailing Address - Country:US
Mailing Address - Phone:404-858-1063
Mailing Address - Fax:
Practice Address - Street 1:20 HERRELL RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5527
Practice Address - Country:US
Practice Address - Phone:770-456-3929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty