Provider Demographics
NPI:1417573114
Name:LIFESTYLE PAIN MANAGEMENT AND WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:LIFESTYLE PAIN MANAGEMENT AND WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:470-395-3618
Mailing Address - Street 1:1982 MAIN ST E STE C
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6461
Mailing Address - Country:US
Mailing Address - Phone:470-395-3618
Mailing Address - Fax:
Practice Address - Street 1:1982 MAIN ST E STE C
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6461
Practice Address - Country:US
Practice Address - Phone:470-395-3618
Practice Address - Fax:770-979-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA66224OtherLICENSE NUMBER