Healthcare Provider Details

I. General information

NPI: 1043089998
Provider Name (Legal Business Name): SOUTHBRDGE HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 RIVERSIDE AVE # 1905
JACKSONVILLE FL
32202-4912
US

IV. Provider business mailing address

851 SOUTHBRIDGE BLVD
SAVANNAH GA
31405-1096
US

V. Phone/Fax

Practice location:
  • Phone: 904-800-9220
  • Fax: 904-674-1843
Mailing address:
  • Phone: 912-657-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DORA AGYEI AGYEMANG
Title or Position: OWNER
Credential: MSN, APRN, ANP-BC
Phone: 912-800-9220