Healthcare Provider Details

I. General information

NPI: 1326225483
Provider Name (Legal Business Name): AMG WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 LAWRENCEVILLE SUWANEE RD STE 112
SUWANEE GA
30024-7049
US

IV. Provider business mailing address

3550 LAWRENCEVILLE SUWANEE RD STE 112
SUWANEE GA
30024-7049
US

V. Phone/Fax

Practice location:
  • Phone: 770-232-9483
  • Fax: 770-232-9493
Mailing address:
  • Phone: 770-232-9483
  • Fax: 770-232-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3101
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number006582
License Number StateGA

VIII. Authorized Official

Name: MS. DONNA M VALENTINO
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-232-9483