Provider Demographics
NPI:1629519343
Name:GEORGIA BRAIN AND SPINE LLC
Entity Type:Organization
Organization Name:GEORGIA BRAIN AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMOS
Authorized Official - Middle Name:O
Authorized Official - Last Name:DARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-418-0192
Mailing Address - Street 1:2107 N DECATUR RD
Mailing Address - Street 2:UNIT 448
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5305
Mailing Address - Country:US
Mailing Address - Phone:404-418-0192
Mailing Address - Fax:844-360-9946
Practice Address - Street 1:2107 N DECATUR RD
Practice Address - Street 2:UNIT 448
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5305
Practice Address - Country:US
Practice Address - Phone:404-418-0192
Practice Address - Fax:844-360-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA64353OtherMEDICAL LICENSE