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General NPI Number Information
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NPI Number | 1871120659
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Entity Type | Organization
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Legal Business Name | BRAIN AND SOUL WELLNESS GROUP, LLC
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Dates
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Enumeration Date | 03/24/2020
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Last Update Date | 05/25/2020
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Provider Practice Location Address
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Address Line | 3050 FIVE FORKS TRICKUM RD SW STE D451
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City | LILBURN
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State | GA
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Zip | 30047-1810
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Country | US
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Telephone | 214-280-0848
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Fax |
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Provider Business Mailing Address
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Address Line | 3050 FIVE FORKS TRICKUM RD SW STE D451
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City | LILBURN
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State | GA
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Zip | 30047-1810
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/MD
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Name | MALOA CHU AFFUEMBEY
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Credential | MD
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Telephone | 404-436-0677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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