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General NPI Number Information
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NPI Number | 1396120291
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Entity Type | Organization
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Legal Business Name | BIG HART WELLNESS AND SPORTS ACADEMY
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Dates
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Enumeration Date | 07/22/2015
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Last Update Date | 07/22/2015
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Provider Practice Location Address
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Address Line | 2021 W LIDDELL RD SUITE B
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City | DULUTH
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State | GA
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Zip | 30096-8831
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Country | US
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Telephone | 702-301-4432
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Fax |
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Provider Business Mailing Address
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Address Line | 5991 THOMPSON MILL RD
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City | HOSCHTON
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State | GA
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Zip | 30548-4029
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Country | US
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Telephone | 702-301-4432
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. EDGERTON HARTWELL
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Credential |
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Telephone | 702-301-4432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number |
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License Number State |
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