=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487198685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY WELLNESS SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2016
-----------------------------------------------------
Last Update Date | 12/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7050 JIMMY CARTER BLVD SUITE 212
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-828-8091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7050 JIMMY CARTER BLVD SUITE 212
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-828-8091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF
-----------------------------------------------------
Name | SAHIL LALWANI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-300-1190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 27038
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------