Provider Demographics
NPI:1134909542
Name:PAIN TREATMENT CENTERS OF GEORGIA LLC
Entity type:Organization
Organization Name:PAIN TREATMENT CENTERS OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROV-KONDRATOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-910-3777
Mailing Address - Street 1:604 W OGLETHORPE HWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4415
Mailing Address - Country:US
Mailing Address - Phone:912-910-3777
Mailing Address - Fax:912-292-0005
Practice Address - Street 1:3760 US HIGHWAY 17 UNIT 11
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3378
Practice Address - Country:US
Practice Address - Phone:912-910-3777
Practice Address - Fax:912-292-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain