Provider Demographics
NPI:1457690554
Name:GEORGIA PAIN AND WELLNESS, LLC
Entity Type:Organization
Organization Name:GEORGIA PAIN AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-235-2401
Mailing Address - Street 1:552 PONCE DE LEON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1806
Mailing Address - Country:US
Mailing Address - Phone:678-235-2401
Mailing Address - Fax:678-235-2403
Practice Address - Street 1:552 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1806
Practice Address - Country:US
Practice Address - Phone:678-235-2401
Practice Address - Fax:678-235-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain