1992878391 NPI number — SOUTH ATLANTA SPINE AND WELLNESS CENTER

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 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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