Provider Demographics
NPI:1285401901
Name:LA CLINIQUE LLC
Entity type:Organization
Organization Name:LA CLINIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMSES
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA-CASASNOVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-688-6240
Mailing Address - Street 1:1240 N THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3605
Mailing Address - Country:US
Mailing Address - Phone:706-229-9313
Mailing Address - Fax:706-229-9388
Practice Address - Street 1:1240 N THORNTON AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3605
Practice Address - Country:US
Practice Address - Phone:706-229-9313
Practice Address - Fax:706-229-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty