Provider Demographics
NPI:1326236894
Name:PEACHTREE SPINE & PAIN PHYSICIANS
Entity Type:Organization
Organization Name:PEACHTREE SPINE & PAIN PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DESTRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SETSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-375-0800
Mailing Address - Street 1:3607 OLD CONEJO RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:770-640-2204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABG7320928332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site