MEDICARE: GEORGIA PAIN AND WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1457690554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA PAIN AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	678-235-2401
Fax Number	:	678-235-2403

Provider Business Practice Location Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	678-235-2401
Fax Number	:	678-235-2403

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	REGINA BANKS
Credential	:
Telephone Number	:	678-235-2401

Provider Enumeration Date	:	02/08/2013
Last Update Date	:	02/08/2013

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