Provider Demographics
NPI:1902957541
Name:WILDWOOD SANITARIUM INCORPORATED
Entity Type:Organization
Organization Name:WILDWOOD SANITARIUM INCORPORATED
Other - Org Name:WILDWOOD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VAUGHAN
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:SPARROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-820-1493
Mailing Address - Street 1:P.O BOX 129
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30757-0129
Mailing Address - Country:US
Mailing Address - Phone:706-820-1493
Mailing Address - Fax:706-820-7459
Practice Address - Street 1:435 LIFESTYLE LANE
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:GA
Practice Address - Zip Code:30757-0129
Practice Address - Country:US
Practice Address - Phone:706-820-1493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41198282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital