Healthcare Provider Details

I. General information

NPI: 1053719393
Provider Name (Legal Business Name): PCA INTERVENTIONAL SPINE AT MACQUARIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 PEACHTREE ST NW SUITE 775
ATLANTA GA
30309-2519
US

IV. Provider business mailing address

PO BOX 40166
BELFAST ME
04915-1241
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-7654
  • Fax: 770-692-6082
Mailing address:
  • Phone: 888-488-8289
  • Fax: 502-919-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RODRIGO DURALDE
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 404-351-7654