=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780461293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SARA JANE WELLNESS BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2023
-----------------------------------------------------
Last Update Date | 09/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 WESTPARK CT STE 200
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-737-1822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 WESTPARK CT STE 200
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-737-1822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | SARA SAAVEDRA
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 678-737-1822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------