Healthcare Provider Details

I. General information

NPI: 1245906981
Provider Name (Legal Business Name): PCW ALLERGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 11/22/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 KLONDIKE RD SW STE 205
CONYERS GA
30094-5173
US

IV. Provider business mailing address

1506 KLONDIKE RD SW STE 205
CONYERS GA
30094-5173
US

V. Phone/Fax

Practice location:
  • Phone: 470-377-6106
  • Fax:
Mailing address:
  • Phone: 470-377-6106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CHANTEL G RUNNELS
Title or Position: DIRECTOR OF OPERATIONS
Credential: MBA
Phone: 470-552-2277