Healthcare Provider Details

I. General information

NPI: 1396495206
Provider Name (Legal Business Name): TRISTAR INJURY CENTER OF DECATUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 CANDLER RD
DECATUR GA
30032-6410
US

IV. Provider business mailing address

3441 LAWRENCEVILLE SUWANEE RD STE C
SUWANEE GA
30024-6503
US

V. Phone/Fax

Practice location:
  • Phone: 678-730-6240
  • Fax:
Mailing address:
  • Phone: 678-730-6240
  • Fax: 678-730-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEX JUTIS
Title or Position: OWNER
Credential: DC
Phone: 678-730-6240