MEDICARE: LUCENT INTEGRATIVE WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1104643782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCENT INTEGRATIVE WELLNESS

Provider Business Mailing Address
First Line	:	128 MARSHALL RD
Second Line	:
City	:	BUCKHEAD
State	:	GA
Zip	:	30625-2906
Country	:	US
Telephone Number	:	706-997-7266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1097 GREENSBORO RD STE 102
Second Line	:
City	:	EATONTON
State	:	GA
Zip	:	31024-9510
Country	:	US
Telephone Number	:	706-997-7266
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. URSULA F. WALLER
Credential	:	DNAP, CRNA
Telephone Number	:	706-997-7266

Provider Enumeration Date	:	09/24/2024
Last Update Date	:	09/24/2024

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Directions to “LUCENT INTEGRATIVE WELLNESS ” Practice Location

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