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General NPI Number Information
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NPI Number | 1275356826
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Entity Type | Organization
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Legal Business Name | ESSENTIA INTIMA LLC
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Dates
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Enumeration Date | 11/04/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 600 LANIER AVE W STE 203
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1833
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Country | US
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Telephone | 909-994-1048
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Fax |
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Provider Business Mailing Address
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Address Line | 600 LANIER AVE W STE 203
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1833
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Country | US
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Telephone | 909-994-1048
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Fax |
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Authorized Official
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Title or Position | CMO
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Name | IJEOMA OKWANDU
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Credential |
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Telephone | 909-994-1048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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