MEDICARE: ALLENS 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	225700000X	Massage Therapist	MT006522	GA

General Provider Information

NPI Number	:	1336592278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLENS WELLNESS

Provider Business Mailing Address
First Line	:	4310 GLENRIDGE STRATFORD DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-4928
Country	:	US
Telephone Number	:	770-905-0415
Fax Number	:

Provider Business Practice Location Address
First Line	:	6010 SANDY SPRINGS CIR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-3871
Country	:	US
Telephone Number	:	770-905-0415
Fax Number	:

Authorized Official
Title or Position	:	ORGANIZER
Name	:	MR. JOSHUA JEROME ALLEN
Credential	:	LMT, NMT, PT
Telephone Number	:	770-905-0415

Provider Enumeration Date	:	07/15/2016
Last Update Date	:	07/15/2016

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