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General NPI Number Information
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NPI Number | 1487041745
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Entity Type | Organization
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Legal Business Name | PHYSICAL WELLNESS GROUP, LLC
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Dates
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Enumeration Date | 04/23/2015
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Last Update Date | 04/23/2015
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Provider Practice Location Address
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Address Line | 4153 FLAT SHOALS PKWY BLDG A
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City | DECATUR
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State | GA
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Zip | 30034-4106
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Country | US
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Telephone | 888-683-2304
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Fax |
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Provider Business Mailing Address
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Address Line | 11877 DOUGLAS RD STE 102299
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City | JOHNS CREEK
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State | GA
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Zip | 30005-4325
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Country | US
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Telephone | 888-683-2304
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | HARVEY B LESLIE
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Credential | M.D.
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Telephone | 888-683-2304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 027597
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License Number State | GA
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