Healthcare Provider Details

I. General information

NPI: 1134374259
Provider Name (Legal Business Name): THE PAIN MANAGEMENT CLINIC OF WOODSTOCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WASHINGTON AVE STE C
GAINESVILLE GA
30501-4100
US

IV. Provider business mailing address

3 WASHINGTON AVE STE C
GAINESVILLE GA
30501-4100
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-2300
  • Fax: 770-534-2900
Mailing address:
  • Phone: 770-534-2300
  • Fax: 770-534-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number058478
License Number StateGA

VIII. Authorized Official

Name: VICTORIA CAMBURAKO
Title or Position: OWNER
Credential:
Phone: 770-534-2300