Provider Demographics
NPI:1205431368
Name:LASER SPINE & PAIN CENTERS PRADO LLC
Entity type:Organization
Organization Name:LASER SPINE & PAIN CENTERS PRADO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINAYA
Authorized Official - Middle Name:KRISHNA
Authorized Official - Last Name:PUPPALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-340-7215
Mailing Address - Street 1:403 PERMIAN WAY STE D
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3226
Mailing Address - Country:US
Mailing Address - Phone:770-627-7246
Mailing Address - Fax:404-393-1611
Practice Address - Street 1:5505 ROSWELL RD STE 350B
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-1985
Practice Address - Country:US
Practice Address - Phone:770-627-7246
Practice Address - Fax:404-393-1611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical