Healthcare Provider Details

I. General information

NPI: 1952937468
Provider Name (Legal Business Name): ALPHA NUTRITION & WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 STATE BRIDGE RD STE E101
JOHNS CREEK GA
30022-2641
US

IV. Provider business mailing address

801 LOCUST GROVE CT
ALPHARETTA GA
30004-1157
US

V. Phone/Fax

Practice location:
  • Phone: 678-538-8696
  • Fax: 478-419-3990
Mailing address:
  • Phone: 678-537-1068
  • Fax: 478-419-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. VERONICA O OKWOCHE
Title or Position: DIRECTOR
Credential: PHD
Phone: 678-538-8696