Provider Demographics
NPI:1114733250
Name:VIDALIA FAMILY CARE LLC
Entity type:Organization
Organization Name:VIDALIA FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:912-293-3308
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0645
Mailing Address - Country:US
Mailing Address - Phone:912-293-3308
Mailing Address - Fax:
Practice Address - Street 1:1702 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7219
Practice Address - Country:US
Practice Address - Phone:912-805-2198
Practice Address - Fax:912-805-2997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care