# IDLEWOOD MEDICAL CLINIC INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316249246
- **Authorized official:** AIDA ROSA DE LA VEGA (CEO)
- **Authorized official phone:** (305) 388-4383

## Contact information

- **Practice address:** 2157 IDLEWOOD RD, STE B, TUCKER, GA 30084-4832
- **Practice address phone:** (305) 388-4383
- **Practice address fax:** (305) 388-4380
- **Mailing address:** 2157 IDLEWOOD RD, STE B, TUCKER, GA 30084-4832
- **Mailing address phone:** (305) 388-4383
- **Mailing address fax:** (305) 388-4380

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | — | NULL | Yes |
| 207QA0505X | Adult Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 11/29/2010
- **Last updated:** 12/17/2010