Healthcare Provider Details

I. General information

NPI: 1124742218
Provider Name (Legal Business Name): DELTA COMPREHENSIVE INJURY AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 MULKEY RD STE 1314
AUSTELL GA
30106-1122
US

IV. Provider business mailing address

1790 MULKEY RD STE 1314
AUSTELL GA
30106-1122
US

V. Phone/Fax

Practice location:
  • Phone: 770-284-3832
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOSE MARTI
Title or Position: OWNER
Credential:
Phone: 678-401-3033