Provider Demographics
NPI:1417054669
Name:CHRONIC PAIN CLINICS OF AMERICA LLC
Entity Type:Organization
Organization Name:CHRONIC PAIN CLINICS OF AMERICA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:STUDENIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-784-7722
Mailing Address - Street 1:1395 S MARIETTA PKWY SE
Mailing Address - Street 2:BLDG 100 STE 101
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4440
Mailing Address - Country:US
Mailing Address - Phone:770-425-8700
Mailing Address - Fax:770-425-8740
Practice Address - Street 1:1395 S MARIETTA PKWY SE
Practice Address - Street 2:BLDG 100 STE 101
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-4440
Practice Address - Country:US
Practice Address - Phone:770-425-8700
Practice Address - Fax:770-425-8740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6996Medicare ID - Type Unspecified