Healthcare Provider Details

I. General information

NPI: 1396571147
Provider Name (Legal Business Name): FLY WHEEL CENTER GA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 OLD ROSWELL LAKES PKWY STE 310
ROSWELL GA
30076-8667
US

IV. Provider business mailing address

174 WHITE ST
LAKEWOOD NJ
08701-4054
US

V. Phone/Fax

Practice location:
  • Phone: 347-661-6533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHRAGA F WAXMAN
Title or Position: OWNER
Credential:
Phone: 347-661-6533