Provider Demographics
NPI:1447791074
Name:PCA INTERVENTIONAL SPINE AT FAYETTE, LLC
Entity Type:Organization
Organization Name:PCA INTERVENTIONAL SPINE AT FAYETTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:DURALDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-351-7654
Mailing Address - Street 1:1800 PEACHTREE ST NW
Mailing Address - Street 2:SUITE 750
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1233 HIGHWAY 54 W
Practice Address - Street 2:SUITE 205
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4542
Practice Address - Country:US
Practice Address - Phone:404-351-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAIN PROCESS261QA1903X
261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical