=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780337337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORCROSS WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2022
-----------------------------------------------------
Last Update Date | 02/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3850 HOLCOMB BRIDGE RD STE 215
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-5219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-305-1430
-----------------------------------------------------
Fax | 770-637-5377
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3850 HOLCOMB BRIDGE RD STE 215
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-5219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 770-637-5377
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | JUSTIN HEILIG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-305-1430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------