Healthcare Provider Details

I. General information

NPI: 1306019674
Provider Name (Legal Business Name): WELLPOINT ACUPUNCTURE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 SOUTHERLAND TER NE
ATLANTA GA
30307-2346
US

IV. Provider business mailing address

372 SOUTHERLAND TER NE
ATLANTA GA
30307-2346
US

V. Phone/Fax

Practice location:
  • Phone: 404-444-7160
  • Fax:
Mailing address:
  • Phone: 404-444-7160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number117
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7706
License Number StateGA

VIII. Authorized Official

Name: MARY COOK
Title or Position: PRESIDENT/OWNER
Credential: PT, LAC
Phone: 404-444-7160