Provider Demographics
NPI:1548459860
Name:PAVILION SPINE SURGERY CENTER LLC
Entity type:Organization
Organization Name:PAVILION SPINE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KABAKIBOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-603-9090
Mailing Address - Street 1:3193 HOWELL MILL RD NW
Mailing Address - Street 2:STE. #315
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2119
Mailing Address - Country:US
Mailing Address - Phone:404-603-9090
Mailing Address - Fax:404-603-9634
Practice Address - Street 1:3193 HOWELL MILL RD NW
Practice Address - Street 2:STE. #315
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2119
Practice Address - Country:US
Practice Address - Phone:404-603-9090
Practice Address - Fax:404-603-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical