=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427394618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLAND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2012
-----------------------------------------------------
Last Update Date | 12/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 N HIGHLAND AVE NE SUITE F
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-351-0043
-----------------------------------------------------
Fax | 888-270-6380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 N HIGHLAND AVE NE SUITE F
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-351-0043
-----------------------------------------------------
Fax | 888-270-6380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. JANET D PALMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-351-0043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 19354
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------