Healthcare Provider Details

I. General information

NPI: 1003472036
Provider Name (Legal Business Name): ANNUAL WELLNESS CENTERS OF AMERICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 OLD NORCROSS RD STE B
LAWRENCEVILLE GA
30046-4312
US

IV. Provider business mailing address

5942 WATERSDOWN WAY
FLOWERY BRANCH GA
30542-3221
US

V. Phone/Fax

Practice location:
  • Phone: 770-545-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: TYLER PENROD
Title or Position: BILLER
Credential:
Phone: 832-289-9225