=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508563651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER VOYAGE WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2023
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2230 TOWNE LAKE PKWY BLDG 900 STE 250
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30189-5584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-713-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2230 TOWNE LAKE PKWY STE 250
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30189-5584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-713-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEFF BAUCOM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-713-4280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2472E0500X
-----------------------------------------------------
Taxonomy Name | EEG Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------