Basic Information
| Provider Information | |||||||||
| NPI: | 1750707246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVINCI PAIN AND WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 MALL OF GEORGIA BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305198761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
| FaxNumber: | 1111111111 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 MALL OF GEORGIA BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305198761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
| FaxNumber: | 1111111111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2014 | ||||||||
| LastUpdateDate: | 03/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | FREIBERGER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 1111111111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 66370 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.