=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952276966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2025
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5755 N POINT PKWY STE 267
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-1175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-373-8981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5755 N POINT PKWY STE 267
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-1175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-373-8981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTING
-----------------------------------------------------
Name | LACIE WEAVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-708-0881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------