Healthcare Provider Details

I. General information

NPI: 1295346781
Provider Name (Legal Business Name): THE HEMLOCK PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST
THOMASTON GA
30286-6209
US

IV. Provider business mailing address

101 PRESTON CT STE 103
MACON GA
31210-5771
US

V. Phone/Fax

Practice location:
  • Phone: 706-307-6055
  • Fax: 478-745-1225
Mailing address:
  • Phone: 478-745-2385
  • Fax: 478-745-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN N. TAFOR
Title or Position: PRESIDENT
Credential: MD
Phone: 478-745-2385