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General NPI Number Information
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NPI Number | 1104643782
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Entity Type | Organization
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Legal Business Name | LUCENT INTEGRATIVE WELLNESS
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Dates
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Enumeration Date | 09/24/2024
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Last Update Date | 09/24/2024
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Provider Practice Location Address
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Address Line | 1097 GREENSBORO RD STE 102
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City | EATONTON
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State | GA
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Zip | 31024-9510
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Country | US
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Telephone | 706-997-7266
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Fax |
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Provider Business Mailing Address
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Address Line | 128 MARSHALL RD
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City | BUCKHEAD
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State | GA
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Zip | 30625-2906
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Country | US
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Telephone | 706-997-7266
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. URSULA F. WALLER
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Credential | DNAP, CRNA
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Telephone | 706-997-7266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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