Healthcare Provider Details

I. General information

NPI: 1689798811
Provider Name (Legal Business Name): PROSPORT WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 POWERS FERRY RD. SUITE A
MARIETTA GA
30067
US

IV. Provider business mailing address

5464 PEACHTREE INDUSTRIAL BLVD
CHAMBLEE GA
30341
US

V. Phone/Fax

Practice location:
  • Phone: 770-454-8300
  • Fax: 770-986-9962
Mailing address:
  • Phone: 770-454-8300
  • Fax: 770-986-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR005750
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL B WAX
Title or Position: CEO
Credential: D.C.
Phone: 770-454-8300