Healthcare Provider Details

I. General information

NPI: 1902163991
Provider Name (Legal Business Name): PATHWAY TO WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 OLD PETERSBURG RD 4111 OLD PETERSBURG RD
MARTINEZ GA
30907-3346
US

IV. Provider business mailing address

4111 OLD PETERSBURG RD 4111 OLD PETERSBURG RD
MARTINEZ GA
30907-3346
US

V. Phone/Fax

Practice location:
  • Phone: 706-228-2929
  • Fax:
Mailing address:
  • Phone: 706-228-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number060968
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number060968
License Number StateGA

VIII. Authorized Official

Name: DR. IMO F NDEM
Title or Position: MEDICAL DIRECTOR/PHYSICIAN
Credential: M.D,M.P.H
Phone: 706-228-2929