=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255668794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLAM ENTERPRISES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 11/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1394 E STONEYBROOK DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-6139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1394 E STONEYBROOK DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-6139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. JODI WHELCHEL BELLAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-949-6139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 048-R-0573
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------