Provider Demographics
NPI: | 1952680928 |
---|---|
Name: | ATLANTA SPINE WELLNESS CENTER LLC |
Entity Type: | Organization |
Organization Name: | ATLANTA SPINE WELLNESS CENTER LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BILLING |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | SARA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BADIE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 770-876-6964 |
Mailing Address - Street 1: | 608 MORELAND AVE NE |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30307-1425 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 404-687-2382 |
Mailing Address - Fax: | 770-452-2844 |
Practice Address - Street 1: | 608 MORELAND AVE NE |
Practice Address - Street 2: | |
Practice Address - City: | ATLANTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30307-1425 |
Practice Address - Country: | US |
Practice Address - Phone: | 404-687-2382 |
Practice Address - Fax: | 770-452-2844 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-08-09 |
Last Update Date: | 2011-08-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | CHIR008167 | 305R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 305R00000X | Managed Care Organizations | Preferred Provider Organization |