Healthcare Provider Details

I. General information

NPI: 1851035778
Provider Name (Legal Business Name): COLORECTAL WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 HIGHWAY 54 W STE 205
FAYETTEVILLE GA
30214-4538
US

IV. Provider business mailing address

1275 HIGHWAY 54 W STE 205
FAYETTEVILLE GA
30214-4538
US

V. Phone/Fax

Practice location:
  • Phone: 770-325-2275
  • Fax: 833-707-2404
Mailing address:
  • Phone: 770-325-2275
  • Fax: 833-707-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIN KING-MULLINS
Title or Position: OWNER
Credential: MD
Phone: 504-473-3237