Healthcare Provider Details

I. General information

NPI: 1619446440
Provider Name (Legal Business Name): HEALTHY YOU LIFESTYLE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2018
Last Update Date: 11/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13225 CARIS CT
ALPHARETTA GA
30009-3249
US

IV. Provider business mailing address

13225 CARIS CT
ALPHARETTA GA
30009-3249
US

V. Phone/Fax

Practice location:
  • Phone: 919-656-1029
  • Fax:
Mailing address:
  • Phone: 919-656-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAJITHA BOMMAKANTI
Title or Position: PRESIDENT
Credential: RN
Phone: 919-656-1029