Provider Demographics
NPI:1386361756
Name:VIVASALUD CLINIC 1 LLC
Entity type:Organization
Organization Name:VIVASALUD CLINIC 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:470-607-5533
Mailing Address - Street 1:2336 WISTERIA DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2336 WISTERIA DR STE 110
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6162
Practice Address - Country:US
Practice Address - Phone:470-342-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003284553AMedicaid