Healthcare Provider Details

I. General information

NPI: 1922794676
Provider Name (Legal Business Name): PROFOUND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 11/23/2023
Certification Date: 11/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 RIVER GREEN PKWY STE 320
DULUTH GA
30096-8337
US

IV. Provider business mailing address

3954 RIVERSTONE DR
SUWANEE GA
30024-1894
US

V. Phone/Fax

Practice location:
  • Phone: 470-323-7665
  • Fax: 877-519-1412
Mailing address:
  • Phone: 470-573-7384
  • Fax: 877-519-1412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: AREIGNA PRESTON
Title or Position: OWNER/MANAGER
Credential: OMT, LMT, BCTMB
Phone: 470-323-6020