Provider Demographics
NPI:1114101946
Name:TRINITY PAIN RELIEF CENTER LLC
Entity Type:Organization
Organization Name:TRINITY PAIN RELIEF CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FRASER-SWORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-478-1300
Mailing Address - Street 1:9434 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-6092
Mailing Address - Country:US
Mailing Address - Phone:770-478-1300
Mailing Address - Fax:770-478-9385
Practice Address - Street 1:9434 S MAIN ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8711
Practice Address - Country:US
Practice Address - Phone:770-478-1300
Practice Address - Fax:770-478-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2020-02-21
Deactivation Date:2020-01-30
Deactivation Code:
Reactivation Date:2020-02-21
Provider Licenses
StateLicense IDTaxonomies
GACHIR006745111N00000X
GACHIR007730111N00000X
GA19354207Q00000X
GAPT006876208100000X
208600000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA02BDCMSMedicare PIN
GA511G700438Medicare PIN
GA6080230001Medicare NSC