1235921412 NPI number — PCOS SISTERS TELEHEALTH CLINIC & WELLNESS CENTER, LLC

Table of content: (NPI 1235921412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235921412 NPI number — PCOS SISTERS TELEHEALTH CLINIC & WELLNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PCOS SISTERS TELEHEALTH CLINIC & 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:
1235921412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
528 SCOTT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30030-2353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-531-1019
Provider Business Mailing Address Fax Number:
888-597-2357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 TOUCHTON RD E STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-8299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-586-1964
Provider Business Practice Location Address Fax Number:
888-597-2357
Provider Enumeration Date:
05/21/2025

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
LYNSEY
Authorized Official Middle Name:
AMANDA
Authorized Official Title or Position:
CEO, MEMBER
Authorized Official Telephone Number:
912-531-1019

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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