Healthcare Provider Details

I. General information

NPI: 1679386809
Provider Name (Legal Business Name): QUEEN CITY ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 BROAD ST
AUGUSTA GA
30901-1214
US

IV. Provider business mailing address

6163 VERMILION LOOP
GRANITEVILLE SC
29829-3261
US

V. Phone/Fax

Practice location:
  • Phone: 951-553-3051
  • Fax:
Mailing address:
  • Phone: 951-553-3051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: ASET AUGUST
Title or Position: HOLISTIC NUTRITIONIST COUNSELOR
Credential: CERTIFIED
Phone: 951-553-3051