Healthcare Provider Details

I. General information

NPI: 1952680928
Provider Name (Legal Business Name): ATLANTA SPINE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 MORELAND AVE NE
ATLANTA GA
30307-1425
US

IV. Provider business mailing address

608 MORELAND AVE NE
ATLANTA GA
30307-1425
US

V. Phone/Fax

Practice location:
  • Phone: 404-687-2382
  • Fax: 770-452-2844
Mailing address:
  • Phone: 404-687-2382
  • Fax: 770-452-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberCHIR008167
License Number StateGA

VIII. Authorized Official

Name: MS. SARA BADIE
Title or Position: BILLING
Credential:
Phone: 770-876-6964