1447791074 NPI number — PCA INTERVENTIONAL SPINE AT FAYETTE, LLC

Table of content: (NPI 1447791074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447791074 NPI number — PCA INTERVENTIONAL SPINE AT FAYETTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PCA INTERVENTIONAL SPINE AT FAYETTE, LLC
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:
1447791074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40061
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-1237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-488-8289
Provider Business Mailing Address Fax Number:
502-919-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 HIGHWAY 54 W
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-4542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-351-7654
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DURALDE
Authorized Official First Name:
RODRIGO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-351-7654

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  IN PROCESS , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com