Healthcare Provider Details

I. General information

NPI: 1154761385
Provider Name (Legal Business Name): GEORGIA WELLNESS ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 PONCE DE LEON AVE NE
ATLANTA GA
30308-1806
US

IV. Provider business mailing address

552 PONCE DE LEON AVE NE
ATLANTA GA
30308-1806
US

V. Phone/Fax

Practice location:
  • Phone: 678-235-2401
  • Fax: 678-235-2403
Mailing address:
  • Phone: 678-235-2401
  • Fax: 678-235-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA M TATE
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-910-2922