MEDICARE: THE INJURY WELLNESS SURGICAL AND PROCEDURE INSTITUTE 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	174400000X	Specialist

General Provider Information

NPI Number	:	1922379304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE INJURY WELLNESS SURGICAL AND PROCEDURE INSTITUTE LLC

Provider Business Mailing Address
First Line	:	2483 POWDER SPRINGS RD SW
Second Line	:	STE C
City	:	MARIETTA
State	:	GA
Zip	:	30064-4573
Country	:	US
Telephone Number	:	770-439-7575
Fax Number	:	770-439-7550

Provider Business Practice Location Address
First Line	:	2483 POWDER SPRINGS RD SW
Second Line	:	STE C
City	:	MARIETTA
State	:	GA
Zip	:	30064-4573
Country	:	US
Telephone Number	:	770-439-7575
Fax Number	:	770-439-7550

Authorized Official
Title or Position	:	COO
Name	:	LIONEL TERRY JOHNSON
Credential	:
Telephone Number	:	770-439-7575

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	01/18/2012

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