Healthcare Provider Details

I. General information

NPI: 1487671475
Provider Name (Legal Business Name): SOUTHLAND SPORTS MEDICINE AND WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 E MAIN ST
BLUE RIDGE GA
30513-4575
US

IV. Provider business mailing address

809 E MAIN ST
BLUE RIDGE GA
30513-4575
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33624
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK LESKI
Title or Position: OWNER/ PHYSICIAN
Credential: MD
Phone: 706-632-2200