Provider Demographics
NPI:1811342561
Name:THE MIGRAINE AND SPINE CLINIC OF VALDOSTA LLC
Entity type:Organization
Organization Name:THE MIGRAINE AND SPINE CLINIC OF VALDOSTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-333-9838
Mailing Address - Street 1:3315 N VALDOSTA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1107
Mailing Address - Country:US
Mailing Address - Phone:229-333-9838
Mailing Address - Fax:229-333-9839
Practice Address - Street 1:3315 N VALDOSTA RD
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1107
Practice Address - Country:US
Practice Address - Phone:229-333-9838
Practice Address - Fax:229-333-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA603292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty