Provider Demographics
NPI:1043537905
Name:PRIMACARE PAIN & REHAB.,LLC
Entity Type:Organization
Organization Name:PRIMACARE PAIN & REHAB.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KHAMIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-284-5556
Mailing Address - Street 1:4467 GLENWOOD RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-5014
Mailing Address - Country:US
Mailing Address - Phone:404-284-5556
Mailing Address - Fax:404-284-5557
Practice Address - Street 1:4467 GLENWOOD RD
Practice Address - Street 2:SUITE 2
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-5014
Practice Address - Country:US
Practice Address - Phone:404-284-5556
Practice Address - Fax:404-284-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019313261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain