Healthcare Provider Details

I. General information

NPI: 1558970640
Provider Name (Legal Business Name): FX SPINE AND PERFORMANCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SRP DR STE B
EVANS GA
30809-4358
US

IV. Provider business mailing address

824 KESTREL DR
EVANS GA
30809-0328
US

V. Phone/Fax

Practice location:
  • Phone: 706-842-6800
  • Fax: 706-842-6780
Mailing address:
  • Phone: 717-557-5926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS ALLAN DEANGELO
Title or Position: PRESIDENT
Credential: DO
Phone: 717-557-5926