Healthcare Provider Details

I. General information

NPI: 1326653783
Provider Name (Legal Business Name): IVYDALE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 RESOURCE PKWY
WINDER GA
30680-8364
US

IV. Provider business mailing address

881 IVYDALE LN
LAWRENCEVILLE GA
30045-7818
US

V. Phone/Fax

Practice location:
  • Phone: 770-291-0419
  • Fax:
Mailing address:
  • Phone: 404-819-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. ABLAVI ADODO AGOMESSOU
Title or Position: PMHNP-C
Credential: NP
Phone: 404-819-8701