Provider Demographics
NPI:1427355106
Name:VIDRO INDUSTRIES, LLC
Entity type:Organization
Organization Name:VIDRO INDUSTRIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-456-4691
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6149
Mailing Address - Country:US
Mailing Address - Phone:770-456-4691
Mailing Address - Fax:
Practice Address - Street 1:20 HERRELL RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5527
Practice Address - Country:US
Practice Address - Phone:770-456-4691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA344112558AMedicaid