NPIMap

Organization Active NPI

Back to Life Medical Group, LLC

  • Family Medicine Physician
  • Canton, GA
National Provider Identifier
1396987152
Registry record updated Nov 10, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
048997 Issued in GA
Legal business name
BACK TO LIFE MEDICAL GROUP, LLC
Practice address
557 Riverstone Pkwy
Suite 140
Canton, GA 30114-5223
Phone
(770) 345-2000
Fax
(770) 345-4524
NPI assigned
Mar 25, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 10, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Eric A Cavaciuti
Title
Owner
Phone
(770) 345-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 048997 GA Primary

Addresses

Primary practice location

557 Riverstone Pkwy
Suite 140
Canton, GA 30114-5223

Mailing address

557 Riverstone Pkwy
Suite 140
Canton, GA 30114-5223
Phone (770) 345-2000

Other names 1

  • Spinal Medical Centers Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090707000351 GA Part B Supplier - Clinic/Group Practice 1658422456 Receives reassigned benefits from 10 practitioners
Practice locations: Canton, GA
O20110503000274 GA DME Supplier - Physician - General Practice 1658422456 Practice locations: Canton, GA

National Provider Directory

National Provider Directory

Locations

557 Riverstone Pkwy
Ste 100
Canton, GA 30114
Phone (770) 345-4520

551 Riverstone Pkwy 100
100
Canton, GA 30114
Phone (770) 345-2000

557 Riverstone Pkwy
Canton, GA 30114
Phone (770) 345-4520

557 Riverstone Pkwy
Ste 140
Canton, GA 30114
Phone (678) 552-6294

551 Riverstone Pkwy Ste 100
Ste 100
Canton, GA 30114
Phone (770) 345-2000

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1237939200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1415577600000",
    "number": "1396987152",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "557 RIVERSTONE PKWY",
            "address_2": "SUITE 140",
            "city": "CANTON",
            "state": "GA",
            "postal_code": "301145223",
            "telephone_number": "770-345-2000",
            "fax_number": "770-345-4524"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "557 RIVERSTONE PKWY",
            "address_2": "SUITE 140",
            "city": "CANTON",
            "state": "GA",
            "postal_code": "301145223",
            "telephone_number": "770-345-2000",
            "fax_number": "770-345-4524"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BACK TO LIFE MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-03-25",
        "last_updated": "2014-11-10",
        "status": "A",
        "authorized_official_last_name": "CAVACIUTI",
        "authorized_official_first_name": "ERIC",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-345-2000",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "048997",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Spinal Medical Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.