1700171485 NPI number — INTERNAL MEDICINE & WELLNESS CENTER OF GA LLC

Table of content: (NPI 1700171485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700171485 NPI number — INTERNAL MEDICINE & WELLNESS CENTER OF GA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE & WELLNESS CENTER OF GA 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:
1700171485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 SAVANNAH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30680-2480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-586-0017
Provider Business Mailing Address Fax Number:
770-586-5460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 SAVANNAH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30680-2480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-586-0017
Provider Business Practice Location Address Fax Number:
770-586-5460
Provider Enumeration Date:
06/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN-BOLDS
Authorized Official First Name:
TAIWANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-586-0017

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com