MEDICARE: MIDTOWN WELLNESS GROUP, INC.

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1346313871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDTOWN WELLNESS GROUP, INC.

Provider Business Mailing Address
First Line	:	1874 PIEDMONT AVE NE
Second Line	:	SUITE 390-C
City	:	ATLANTA
State	:	GA
Zip	:	30324-4869
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1874 PIEDMONT AVE NE
Second Line	:	SUITE 390-C
City	:	ATLANTA
State	:	GA
Zip	:	30324-4869
Country	:	US
Telephone Number	:	786-246-2531
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	FABIAN CENTENO
Credential	:
Telephone Number	:	786-246-2531

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/22/2020

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