=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770761496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAINESVILLE PAIN AND REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2008
-----------------------------------------------------
Last Update Date | 02/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 JESSE JEWELL PKWY SE
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-535-0850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 JESSE JEWELL PKWY SE
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-535-0850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. ANTHONY BARTOLO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 770-535-0850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR006266
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------