Healthcare Provider Details

I. General information

NPI: 1750494423
Provider Name (Legal Business Name): GEORGIA PAIN SPINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MEDICAL DRIVE SUITE 302
CARTERSVILLE GA
30121
US

IV. Provider business mailing address

PO BOX 11407 DEPT 2657
BIRMINGHAM AL
35246-0001
US

V. Phone/Fax

Practice location:
  • Phone: 678-337-3163
  • Fax: 770-422-7306
Mailing address:
  • Phone: 770-920-4950
  • Fax: 770-929-9092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number008-311
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA BECK
Title or Position: CFO
Credential:
Phone: 404-403-8310