Healthcare Provider Details

I. General information

NPI: 1801228481
Provider Name (Legal Business Name): CENTER FOR SPINE INTERVENTIONS ASC 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4586 TIMBER RIDGE DR STE 141
DOUGLASVILLE GA
30135-7517
US

IV. Provider business mailing address

2713 CHARLES HARDY PKWY STE 212
DALLAS GA
30157-9445
US

V. Phone/Fax

Practice location:
  • Phone: 678-813-2741
  • Fax: 770-575-3912
Mailing address:
  • Phone: 678-813-2741
  • Fax: 770-575-3912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANICE RAYA
Title or Position: OFFICE MANAGER
Credential:
Phone: 678-813-2741