1215696869 NPI number — SAPPHIRE AND DIAMOND WELLNESS CENTER, LLC

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 1215696869 NPI number — SAPPHIRE AND DIAMOND WELLNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAPPHIRE AND DIAMOND WELLNESS CENTER, LLC
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:
1215696869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2890 GEORGIA HIGHWAY 212 SW STE A106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30094-3363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-359-5165
Provider Business Mailing Address Fax Number:
470-545-0860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 MILSTEAD RD NE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30012-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-545-0860
Provider Business Practice Location Address Fax Number:
470-300-7778
Provider Enumeration Date:
12/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENSON
Authorized Official First Name:
ELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
470-545-0860

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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