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General NPI Number Information
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NPI Number | 1871087627
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Entity Type | Organization
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Legal Business Name | OPT4WELLNESS, LLC
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Dates
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Enumeration Date | 06/15/2018
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 2039 10TH AVE
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City | COLUMBUS
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State | GA
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Zip | 31901-1459
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Country | US
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Telephone | 706-566-5764
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Fax | 706-566-4377
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Provider Business Mailing Address
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Address Line | 350 OLD GATE RD
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City | MIDLAND
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State | GA
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Zip | 31820-4777
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Country | US
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Telephone | 706-580-4059
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Fax | 706-566-4377
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Authorized Official
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Title or Position | CEO/OWNER
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Name | DR. STANLEY WAYNE HIMES
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Credential | MD
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Telephone | 706-580-4059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 33839
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License Number State | GA
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