Provider Demographics
NPI:1841507621
Name:PAIN RELIEF NETWORK OF THE SOUTH
Entity type:Organization
Organization Name:PAIN RELIEF NETWORK OF THE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-879-0064
Mailing Address - Street 1:374 OSPREY PT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6163
Mailing Address - Country:US
Mailing Address - Phone:678-855-7147
Mailing Address - Fax:770-413-1197
Practice Address - Street 1:2 RAVINIA DR
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-2104
Practice Address - Country:US
Practice Address - Phone:678-855-7147
Practice Address - Fax:770-413-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1081207Q00000X
TN2082207Q00000X
GA33908208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty