Provider Demographics
NPI:1710236385
Name:GWINNETT SPINAL & REHAB. CENTER, P.C.
Entity Type:Organization
Organization Name:GWINNETT SPINAL & REHAB. CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-643-8638
Mailing Address - Street 1:55 W CROSSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 W CROSSVILLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2901
Practice Address - Country:US
Practice Address - Phone:770-643-8638
Practice Address - Fax:770-817-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU76379Medicare UPIN