Healthcare Provider Details

I. General information

NPI: 1932549540
Provider Name (Legal Business Name): CONSERVATIVE SPINE & JOINT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 OLD SNELLVILLE HWY SUITE150
LAWRENCEVILLE GA
30044-6216
US

IV. Provider business mailing address

516 SOSEBEE FARM RD UNIT 159
GRAYSON GA
30017-0103
US

V. Phone/Fax

Practice location:
  • Phone: 770-601-4340
  • Fax: 770-978-1324
Mailing address:
  • Phone: 770-601-4340
  • Fax: 678-442-1324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUBEN DIAZ
Title or Position: OWNER/DIRECTOR
Credential: M.D.
Phone: 678-232-0109