Basic Information
| Provider Information | |||||||||
| NPI: | 1578157020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIDALIA HEALTH SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 MEADOWS LN STE B | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304747201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125355555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1707 MEADOWS LN STE B | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304747201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125355555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2021 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125358691 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIDALIA HEALTH SERVICES, LLC | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
No ID Information.