Provider Demographics
NPI:1346526530
Name:BACK TO LIFE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:BACK TO LIFE MEDICAL GROUP, LLC
Other - Org Name:GEORGIA PAIN TREATMENT CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:CUDDAPAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-345-2000
Mailing Address - Street 1:557 RIVERSTONE PKWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5223
Mailing Address - Country:US
Mailing Address - Phone:770-345-2000
Mailing Address - Fax:770-345-4524
Practice Address - Street 1:557 RIVERSTONE PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5223
Practice Address - Country:US
Practice Address - Phone:770-345-2000
Practice Address - Fax:770-345-4524
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACK TO LIFE MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-01
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site