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General NPI Number Information
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NPI Number | 1386903672
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Entity Type | Organization
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Legal Business Name | PAIN MANAGEMENT & WELLNESS CENTERS OF GEORGIA, LLC
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Dates
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Enumeration Date | 05/08/2012
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Last Update Date | 06/24/2015
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Provider Practice Location Address
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Address Line | 4905 LAVISTA RD SUITE B
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City | TUCKER
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State | GA
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Zip | 30084-4409
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Country | US
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Telephone | 770-680-5740
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Fax | 770-680-5754
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Provider Business Mailing Address
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Address Line | 4905 LAVISTA RD SUITE B
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City | TUCKER
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State | GA
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Zip | 30084-4409
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Country | US
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Telephone | 770-680-5740
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Fax | 770-680-5754
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Authorized Official
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Title or Position | MANAGER
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Name | MR. ABRAHAM COHEN
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Credential |
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Telephone | 770-680-5740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 00228865
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 00228865
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License Number State | GA
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