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General NPI Number Information
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NPI Number | 1043089998
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Entity Type | Organization
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Legal Business Name | SOUTHBRDGE HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 12/20/2023
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Last Update Date | 12/20/2023
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Provider Practice Location Address
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Address Line | 476 RIVERSIDE AVE # 1905
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City | JACKSONVILLE
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State | FL
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Zip | 32202-4912
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Country | US
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Telephone | 904-800-9220
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Fax | 904-674-1843
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Provider Business Mailing Address
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Address Line | 851 SOUTHBRIDGE BLVD
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City | SAVANNAH
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State | GA
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Zip | 31405-1096
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Country | US
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Telephone | 912-657-5256
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DORA AGYEI AGYEMANG
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Credential | MSN, APRN, ANP-BC
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Telephone | 912-800-9220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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