Healthcare Provider Details

I. General information

NPI: 1841736303
Provider Name (Legal Business Name): GWINNETT SPINE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 PLEASANT HILL RD SUITE 215
DULUTH GA
30096-2326
US

IV. Provider business mailing address

1625 PLEASANT HILL RD SUITE 215
DULUTH GA
30096-2326
US

V. Phone/Fax

Practice location:
  • Phone: 470-299-6859
  • Fax: 470-299-8397
Mailing address:
  • Phone: 470-299-6859
  • Fax: 470-299-8397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO08008
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1831215714
License Number StateGA

VIII. Authorized Official

Name: MRS. ANGELA S PIRTLE
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 770-755-9137