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General NPI Number Information
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NPI Number | 1336671379
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Entity Type | Organization
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Legal Business Name | IMPACT WELLNESS CENTER
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/29/2017
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Provider Practice Location Address
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Address Line | 1989 N WILLIAMSBURG DR SUITE E
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City | DECATUR
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State | GA
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Zip | 30033-5998
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Country | US
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Telephone | 678-717-9299
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Fax | 404-492-8885
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Provider Business Mailing Address
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Address Line | 1989 N WILLIAMSBURG DR SUITE E
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City | DECATUR
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State | GA
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Zip | 30033-5998
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Country | US
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Telephone | 678-717-9299
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Fax | 404-492-8885
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Authorized Official
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Title or Position | ADMINISTRATIVE MANAGER
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Name | DR. TEFYLON CAMERON
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Credential | DC
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Telephone | 678-717-9299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | GA050322
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License Number State | GA
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