Provider Demographics
NPI:1891936282
Name:WOODSTOCK PAIN SOLUTIONS, PC
Entity Type:Organization
Organization Name:WOODSTOCK PAIN SOLUTIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MABINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-924-8438
Mailing Address - Street 1:7914 HIGHWAY 92
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5238
Mailing Address - Country:US
Mailing Address - Phone:770-924-8438
Mailing Address - Fax:770-924-8431
Practice Address - Street 1:7914 HIGHWAY 92
Practice Address - Street 2:SUITE 130
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5238
Practice Address - Country:US
Practice Address - Phone:770-924-8438
Practice Address - Fax:770-924-8431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053994261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain