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General NPI Number Information
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NPI Number | 1790155513
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Entity Type | Organization
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Legal Business Name | VITALITY WELLNESS & PAIN LLC
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 01/29/2016
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Provider Practice Location Address
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Address Line | 5885 GLENRIDGE DR STE 200
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City | ATLANTA
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State | GA
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Zip | 30328-5512
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Country | US
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Telephone | 404-567-6608
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Fax |
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Provider Business Mailing Address
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Address Line | 860 JOHNSON FERRY RD STE 140-107
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City | ATLANTA
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State | GA
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Zip | 30342-1435
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Country | US
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Telephone | 404-567-6608
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Fax |
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Authorized Official
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Title or Position | MANAGER/OWNER
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Name | DR. MARK C GUERDAN
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Credential | D.O.
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Telephone | 404-567-6608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State | GA
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