Healthcare Provider Details

I. General information

NPI: 1093308918
Provider Name (Legal Business Name): BWELL MEDICAL AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 STEWART PKWY
DOUGLASVILLE GA
30135-2371
US

IV. Provider business mailing address

5933 STEWART PKWY
DOUGLASVILLE GA
30135-2371
US

V. Phone/Fax

Practice location:
  • Phone: 470-331-9468
  • Fax: 770-234-5717
Mailing address:
  • Phone: 470-331-9468
  • Fax: 770-234-5717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VIVIAN ADU-ABOAGYE
Title or Position: ADMINISTRATOR
Credential: NURSE PRACTITIONER
Phone: 470-331-9468