Healthcare Provider Details

I. General information

NPI: 1447791074
Provider Name (Legal Business Name): PCA INTERVENTIONAL SPINE AT FAYETTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 HIGHWAY 54 W SUITE 205
FAYETTEVILLE GA
30214-4542
US

IV. Provider business mailing address

PO BOX 40061
BELFAST ME
04915-1237
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-7654
  • Fax:
Mailing address:
  • Phone: 888-488-8289
  • Fax: 502-919-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberIN PROCESS
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RODRIGO DURALDE
Title or Position: OWNER
Credential: MD
Phone: 404-351-7654