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General NPI Number Information
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NPI Number | 1700506979
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Entity Type | Organization
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Legal Business Name | ATLANTA WELLNESS MANAGEMENT CENTER, LLC
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Dates
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Enumeration Date | 08/29/2022
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Last Update Date | 10/15/2023
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Provider Practice Location Address
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Address Line | 3840 PEACHTREE INDUSTRIAL BLVD # 140
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City | DULUTH
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State | GA
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Zip | 30096-5031
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Country | US
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Telephone | 470-333-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 3840 PEACHTREE INDUSTRIAL BLVD # 140
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City | DULUTH
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State | GA
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Zip | 30096-5031
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Country | US
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Telephone | 470-333-8000
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Fax |
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Authorized Official
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Title or Position | CENTER OPERATIONS DIRECTOR
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Name | GRACE PARK
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Credential |
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Telephone | 770-880-7668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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