Healthcare Provider Details

I. General information

NPI: 1295330561
Provider Name (Legal Business Name): SPINE , MUSCLE AND JOINT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4319 COVINGTON HWY STE 201
DECATUR GA
30035-1206
US

IV. Provider business mailing address

2090 LAWRENCEVILLE SUWANEE RD. STE A #515
SUWANEE GA
30024
US

V. Phone/Fax

Practice location:
  • Phone: 678-505-0000
  • Fax:
Mailing address:
  • Phone: 678-505-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. VIVEK PATEL
Title or Position: OWNER
Credential:
Phone: 678-505-0000