Healthcare Provider Details

I. General information

NPI: 1760684609
Provider Name (Legal Business Name): GEORGIA SPINE & NEUROSURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 N DECATUR RD SUITE 110
DECATUR GA
30033-6131
US

IV. Provider business mailing address

2675 N DECATUR RD SUITE 110
DECATUR GA
30033-6131
US

V. Phone/Fax

Practice location:
  • Phone: 404-299-3338
  • Fax: 404-299-3315
Mailing address:
  • Phone: 404-299-3338
  • Fax: 404-299-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number51201
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number51201
License Number StateGA

VIII. Authorized Official

Name: KAVEH KHAJAVI
Title or Position: OWNER
Credential: MD
Phone: 404-299-3338