Provider Demographics
NPI:1801282546
Name:LIFE ORTHOPAEDIC & SPINE CENTER
Entity type:Organization
Organization Name:LIFE ORTHOPAEDIC & SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF LIFE ORTHOPAEDIC & SPINE C
Authorized Official - Prefix:DR
Authorized Official - First Name:DASHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-477-1115
Mailing Address - Street 1:4426 TILLY MILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2105
Mailing Address - Country:US
Mailing Address - Phone:770-477-1115
Mailing Address - Fax:770-477-1119
Practice Address - Street 1:4426 TILLY MILL RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30360-2105
Practice Address - Country:US
Practice Address - Phone:770-477-1115
Practice Address - Fax:770-477-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62097208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA032883905CMedicaid
GA202I503878Medicare PIN
GA202I250228Medicare PIN