=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619746385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PKW WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2023
-----------------------------------------------------
Last Update Date | 12/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 HOUZE WAY STE 400
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-329-3322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 HOUZE WAY STE 400
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-329-3322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEVIN BORLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-791-2600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------