=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790957348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLWELL BEHAVIORAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2008
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 OSIGIAN BLVD STE A
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-8928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-333-6711
-----------------------------------------------------
Fax | 478-333-6730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2144
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31099-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-333-6711
-----------------------------------------------------
Fax | 478-333-6730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BABATUNDE FRANCIS FAGBAMIYE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 478-333-6711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 056058
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------