Provider Demographics
NPI:1932801438
Name:TRISTAR INJURY CENTER OF RIVERDALE LLC
Entity Type:Organization
Organization Name:TRISTAR INJURY CENTER OF RIVERDALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:JUTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-730-6240
Mailing Address - Street 1:3441 LAWRENCEVILLE SUWANEE RD STE C
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6503
Mailing Address - Country:US
Mailing Address - Phone:678-730-6240
Mailing Address - Fax:678-730-1005
Practice Address - Street 1:34 UPPER RIVERDALE RD SE STE 206
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2635
Practice Address - Country:US
Practice Address - Phone:404-479-1455
Practice Address - Fax:407-539-8557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty