Healthcare Provider Details

I. General information

NPI: 1396365094
Provider Name (Legal Business Name): BEYOND YOUR ORDINARY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 ATLANTA ST STE 100
MCDONOUGH GA
30253-2192
US

IV. Provider business mailing address

97 ATLANTA ST STE 100
MCDONOUGH GA
30253-2192
US

V. Phone/Fax

Practice location:
  • Phone: 336-268-6469
  • Fax:
Mailing address:
  • Phone: 336-268-6469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MYA CULLINS
Title or Position: CEO
Credential: MS, MAT SPECIALIST
Phone: 336-268-6469