Healthcare Provider Details

I. General information

NPI: 1013665355
Provider Name (Legal Business Name): COMPLETE WELLNESS DIAGNOSTIC LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 RIVERBROOKE WAY NE
CONYERS GA
30012-6624
US

IV. Provider business mailing address

1514 RIVERBROOKE WAY NE
CONYERS GA
30012-6624
US

V. Phone/Fax

Practice location:
  • Phone: 678-643-0885
  • Fax:
Mailing address:
  • Phone: 678-643-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARNIKA PORTER
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 678-643-0885