Healthcare Provider Details

I. General information

NPI: 1215201355
Provider Name (Legal Business Name): AUGUSTA INTERVENTIONAL PAIN AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 INDEPENDENCE DR
AUGUSTA GA
30901-1037
US

IV. Provider business mailing address

720 BON AIR DR
AUGUSTA GA
30907-4872
US

V. Phone/Fax

Practice location:
  • Phone: 419-508-4608
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number67138
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number67138
License Number StateGA

VIII. Authorized Official

Name: DR. VENKATA LAKKIMSETTY
Title or Position: PHYSICIAN
Credential: MD
Phone: 419-508-4608