Provider Demographics
NPI:1023517505
Name:ANTIOCH VASCULAR CENTER, LLC
Entity type:Organization
Organization Name:ANTIOCH VASCULAR CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:J ALPHONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-927-8011
Mailing Address - Street 1:9104 MIDDLEGROUND ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9104 MIDDLEGROUND ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-927-8011
Practice Address - Fax:912-927-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular SpecialistGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty