Healthcare Provider Details

I. General information

NPI: 1902487903
Provider Name (Legal Business Name): DG SPORTS MEDICINE & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 PIEDMONT RD NE STE 56-435
ATLANTA GA
30324-3086
US

IV. Provider business mailing address

2625 PIEDMONT RD NE STE 56-435
ATLANTA GA
30324-3086
US

V. Phone/Fax

Practice location:
  • Phone: 678-749-7020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIARA GROSS
Title or Position: OWNER
Credential: DO
Phone: 678-595-7483