Healthcare Provider Details

I. General information

NPI: 1396120291
Provider Name (Legal Business Name): BIG HART WELLNESS AND SPORTS ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 W LIDDELL RD SUITE B
DULUTH GA
30096-8831
US

IV. Provider business mailing address

5991 THOMPSON MILL RD
HOSCHTON GA
30548-4029
US

V. Phone/Fax

Practice location:
  • Phone: 702-301-4432
  • Fax:
Mailing address:
  • Phone: 702-301-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. EDGERTON HARTWELL
Title or Position: PRESIDENT
Credential:
Phone: 702-301-4432