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General NPI Number Information
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NPI Number | 1184283848
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Entity Type | Organization
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Legal Business Name | SISTAH SPACE WOMEN'S WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 06/06/2019
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Last Update Date | 02/26/2020
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Provider Practice Location Address
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Address Line | 130 HOWELL RD
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City | TYRONE
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State | GA
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Zip | 30290-6800
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Country | US
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Telephone | 312-451-7546
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Fax | 470-250-2401
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Provider Business Mailing Address
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Address Line | 351 LAUREN DR
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City | FAIRBURN
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State | GA
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Zip | 30213-7007
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Country | US
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Telephone | 312-451-7546
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Fax | 470-250-2401
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Authorized Official
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Title or Position | OWNER
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Name | JENEEN A LOMAX
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Credential |
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Telephone | 312-451-7546
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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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