=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457787350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROYAL WELLNESS INTERNATIONAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2013
-----------------------------------------------------
Last Update Date | 09/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2488 SCENIC HWY S
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-289-7150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 BERRYMAN PL
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-8297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-289-7150
-----------------------------------------------------
Fax | 678-377-6836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SUNDAY ALABA FAWOLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-289-7150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 55514
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------