Basic Information
| Provider Information | |||||||||
| NPI: | 1679705115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIDALIA CHILDREN'S CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388484 | ||||||||
| FaxNumber: | 9125388665 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388484 | ||||||||
| FaxNumber: | 9125388665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | OSTEEN | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125385314 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEADT REGIONAL PRIMARY CARE CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.