1750931168 NPI number — GEORGIA PAIN AND WELLNESS CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750931168 NPI number — GEORGIA PAIN AND WELLNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PAIN AND WELLNESS CENTER, 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:
6
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:
1750931168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 PHILIP BLVD STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30046-8768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-962-3642
Provider Business Mailing Address Fax Number:
770-962-3643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 LIBERTY BLVD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-962-3642
Provider Business Practice Location Address Fax Number:
770-962-3643
Provider Enumeration Date:
09/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
AMIT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-962-3642

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; 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