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General NPI Number Information
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NPI Number | 1649677626
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Entity Type | Organization
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Legal Business Name | WONDERFULLY MADE WELLNESS, INC.
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Dates
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Enumeration Date | 11/19/2014
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 464 VININGS VINTAGE CIRCLE SE
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City | MABLETON
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State | GA
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Zip | 30126
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Country | US
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Telephone | 770-853-3216
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Fax |
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Provider Business Mailing Address
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Address Line | 464 VININGS VINTAGE CIRCLE SE
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City | MABLETON
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State | GA
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Zip | 30126
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | QURA WOODBURY
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Credential | MS, ACSM-HFS
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Telephone | 770-853-3216
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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 |
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License Number State |
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