Provider Demographics
NPI:1790155513
Name:VITALITY WELLNESS & PAIN LLC
Entity Type:Organization
Organization Name:VITALITY WELLNESS & PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUERDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:404-567-6608
Mailing Address - Street 1:860 JOHNSON FERRY RD STE 140-107
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1435
Mailing Address - Country:US
Mailing Address - Phone:404-567-6608
Mailing Address - Fax:
Practice Address - Street 1:5885 GLENRIDGE DR
Practice Address - Street 2:STE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5512
Practice Address - Country:US
Practice Address - Phone:404-567-6608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty