Provider Demographics
NPI:1962628669
Name:PARK SPRINGS, LLC
Entity Type:Organization
Organization Name:PARK SPRINGS, LLC
Other - Org Name:PARK SPRINGS WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ISAKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-932-6552
Mailing Address - Street 1:500 SPRINGHOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6718
Mailing Address - Country:US
Mailing Address - Phone:770-879-4330
Mailing Address - Fax:678-684-3066
Practice Address - Street 1:500 SPRINGHOUSE CIR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6718
Practice Address - Country:US
Practice Address - Phone:770-879-4330
Practice Address - Fax:678-684-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
6847Medicare ID - Type UnspecifiedMEDICARE PROVIDER #