Provider Demographics
NPI:1750707246
Name:DAVINCI PAIN AND WELLNESS LLC
Entity type:Organization
Organization Name:DAVINCI PAIN AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREIBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:111-111-1111
Mailing Address - Street 1:2720 MALL OF GEORGIA BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8761
Mailing Address - Country:US
Mailing Address - Phone:111-111-1111
Mailing Address - Fax:111-111-1111
Practice Address - Street 1:2720 MALL OF GEORGIA BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8761
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:111-111-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66370174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty