Healthcare Provider Details

I. General information

NPI: 1255085130
Provider Name (Legal Business Name): GOOD LANDING WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2541 SECOND AVENUE
DACULA GA
30019-3001
US

IV. Provider business mailing address

256 MCMILLAN RD
DACULA GA
30019-2337
US

V. Phone/Fax

Practice location:
  • Phone: 770-450-6120
  • Fax:
Mailing address:
  • Phone: 770-353-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARLIE CAMPBELL
Title or Position: COO
Credential:
Phone: 770-353-9660