Healthcare Provider Details

I. General information

NPI: 1295834976
Provider Name (Legal Business Name): SPECIALTY SPINE INTERVENTION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 JESSE JEWELL PKWY SE STE 300
GAINESVILLE GA
30501-3862
US

IV. Provider business mailing address

1240 JESSE JEWELL PKWY SE STE 300
GAINESVILLE GA
30501-3862
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-7277
  • Fax:
Mailing address:
  • Phone: 770-297-7277
  • Fax:

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: ANNETTE SLOAN
Title or Position: ADMINISTRATOR
Credential: RN,FACMPE,CPC
Phone: 770-297-7277