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General NPI Number Information
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NPI Number | 1144545922
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Entity Type | Organization
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Legal Business Name | OPULENT WELLNESS LLC
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Dates
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Enumeration Date | 04/05/2010
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Last Update Date | 04/05/2010
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Provider Practice Location Address
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Address Line | 2221 PEACHTREE RD NE STE. P33
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City | ATLANTA
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State | GA
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Zip | 30309-1148
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Country | US
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Telephone | 404-955-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 220 26TH ST NW APT. 1117
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City | ATLANTA
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State | GA
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Zip | 30309-1914
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Country | US
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Telephone | 404-955-1000
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KEISHA MONIQUE GWINN
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Credential | MT
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Telephone | 404-955-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | MT004320
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License Number State | GA
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