Provider Demographics
NPI:1982172060
Name:BACK TO LIFE PAIN CENTER, LLC
Entity Type:Organization
Organization Name:BACK TO LIFE PAIN CENTER, LLC
Other - Org Name:BACK TO LIFE PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTIN
Authorized Official - Middle Name:SERGEYEVICH
Authorized Official - Last Name:TSYMBALOV
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-909-0911
Mailing Address - Street 1:410 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3740
Mailing Address - Country:US
Mailing Address - Phone:678-909-0911
Mailing Address - Fax:678-909-0912
Practice Address - Street 1:410 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3740
Practice Address - Country:US
Practice Address - Phone:678-909-0911
Practice Address - Fax:678-909-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty