1992878391 NPI number — SOUTH ATLANTA SPINE AND WELLNESS CENTER

Table of content: (NPI 1992878391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992878391 NPI number — SOUTH ATLANTA SPINE AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ATLANTA SPINE AND WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992878391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
288 HWY 314
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-1385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-817-4053
Provider Business Mailing Address Fax Number:
675-817-4058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
288 HIGHWAY 314
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-817-4053
Provider Business Practice Location Address Fax Number:
675-817-4058
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNET
Authorized Official First Name:
IAN
Authorized Official Middle Name:
BRADLEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-817-4053

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIR006553 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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