1265951289 NPI number — COMPLETE BODY WELLNESS STUDIO, LLC

Table of content: (NPI 1265951289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265951289 NPI number — COMPLETE BODY WELLNESS STUDIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLETE BODY WELLNESS STUDIO, 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:
1265951289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 MILLERS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30004-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-712-5955
Provider Business Mailing Address Fax Number:
770-889-0244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11805 NORTHFALL LN STE 804
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30009-7970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-712-5955
Provider Business Practice Location Address Fax Number:
770-889-0244
Provider Enumeration Date:
09/11/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
GINGER
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
770-712-5955

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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