Healthcare Provider Details

I. General information

NPI: 1740372473
Provider Name (Legal Business Name): PALMETTO HEALTH COUNCIL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 MAIN ST
PALMETTO GA
30268-1138
US

IV. Provider business mailing address

643 MAIN ST
PALMETTO GA
30268-1138
US

V. Phone/Fax

Practice location:
  • Phone: 404-929-8824
  • Fax: 404-929-9769
Mailing address:
  • Phone: 404-929-8824
  • Fax: 404-929-9769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH800040
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberH800040
License Number StateGA

VIII. Authorized Official

Name: DR. JON WILLIAM WOLLENZIEN JR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DBA
Phone: 404-929-8824