Provider Demographics
NPI:1952062713
Name:RESTORE METABOLIX OF VIDALIA
Entity Type:Organization
Organization Name:RESTORE METABOLIX OF VIDALIA
Other - Org Name:RESTOR METABOLIX OF VIDALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:912-294-6712
Mailing Address - Street 1:1805 MANNING DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1805 MANNING DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8921
Practice Address - Country:US
Practice Address - Phone:912-307-2090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy