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General NPI Number Information
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NPI Number | 1306085402
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Entity Type | Organization
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Legal Business Name | CAEDEL WELLNESS CENTER
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Dates
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Enumeration Date | 02/12/2009
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Last Update Date | 02/12/2009
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Provider Practice Location Address
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Address Line | 101 DEVANT ST STE 803
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2716
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Country | US
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Telephone | 678-216-0342
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Fax | 678-216-0348
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Provider Business Mailing Address
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Address Line | PO BOX 9
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-0009
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Country | US
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Telephone | 678-216-0342
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Fax | 678-216-0348
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Authorized Official
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Title or Position | C.E.O
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Name | MS. CLAIRE K WILLIE
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Credential | M.D.
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Telephone | 678-216-0432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 039177
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License Number State | GA
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