Healthcare Provider Details

I. General information

NPI: 1205431368
Provider Name (Legal Business Name): LASER SPINE & PAIN CENTERS PRADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 ROSWELL RD STE 350B
SANDY SPRINGS GA
30342-1985
US

IV. Provider business mailing address

403 PERMIAN WAY STE D
VILLA RICA GA
30180-3226
US

V. Phone/Fax

Practice location:
  • Phone: 770-627-7246
  • Fax: 404-393-1611
Mailing address:
  • Phone: 770-627-7246
  • Fax: 404-393-1611

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: DR. VINAYA KRISHNA PUPPALA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 847-340-7215