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General NPI Number Information
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NPI Number | 1063787901
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Entity Type | Organization
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Legal Business Name | PORT-A-WELLNESS LLC
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Dates
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Enumeration Date | 03/11/2012
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Last Update Date | 03/11/2012
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Provider Practice Location Address
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Address Line | 1670 WASHINGTON AVE
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City | EAST POINT
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State | GA
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Zip | 30344-4248
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Country | US
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Telephone | 678-705-1691
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Fax | 855-289-7475
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Provider Business Mailing Address
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Address Line | 1670 WASHINGTON AVE
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City | EAST POINT
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State | GA
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Zip | 30344-4248
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Country | US
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Telephone | 678-705-1691
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Fax | 855-289-7475
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. RAMONA ANN MINNIS
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Credential | M..D.
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Telephone | 678-705-1691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 042668
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License Number State | GA
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