Healthcare Provider Details

I. General information

NPI: 1841135647
Provider Name (Legal Business Name): I AM WHOLE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 MEMORIAL DR BLDG C
STONE MOUNTAIN GA
30083-3234
US

IV. Provider business mailing address

5405 MEMORIAL DR BLDG C
STONE MOUNTAIN GA
30083-3234
US

V. Phone/Fax

Practice location:
  • Phone: 678-999-2611
  • Fax: 678-999-2611
Mailing address:
  • Phone: 678-999-2611
  • Fax: 678-999-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TINITA SIMMONDS
Title or Position: DIRECTOR
Credential:
Phone: 678-999-2611