Healthcare Provider Details

I. General information

NPI: 1053919225
Provider Name (Legal Business Name): MIND AND BODY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2020
Last Update Date: 08/14/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 MEDLOCK BRIDGE RD STE 820
JOHNS CREEK GA
30097-4437
US

IV. Provider business mailing address

1801 PEACHTREE ST NE STE 300
ATLANTA GA
30309-1859
US

V. Phone/Fax

Practice location:
  • Phone: 404-800-5181
  • Fax: 404-800-5797
Mailing address:
  • Phone: 404-800-5181
  • Fax: 404-800-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MOSHE BACHAR
Title or Position: PHYSICIAN
Credential: MD
Phone: 404-800-5181