1447021456 NPI number — WELLNESS TRACK 360

Table of content: (NPI 1447021456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447021456 NPI number — WELLNESS TRACK 360

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS TRACK 360
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:
1447021456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 HURT PLZ SE STE 1650
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30303-2946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-456-4280
Provider Business Mailing Address Fax Number:
478-451-0224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 HURT PLZ SE STE 1650
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30303-2946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-456-4280
Provider Business Practice Location Address Fax Number:
478-451-0224
Provider Enumeration Date:
01/10/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FLOURNOY
Authorized Official First Name:
CALEB
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
478-456-4280

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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