MEDICARE: PORT-A-WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	042668	GA

General Provider Information

NPI Number	:	1063787901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT-A-WELLNESS LLC

Provider Business Mailing Address
First Line	:	1670 WASHINGTON AVE
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-4248
Country	:	US
Telephone Number	:	678-705-1691
Fax Number	:	855-289-7475

Provider Business Practice Location Address
First Line	:	1670 WASHINGTON AVE
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-4248
Country	:	US
Telephone Number	:	678-705-1691
Fax Number	:	855-289-7475

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. RAMONA ANN MINNIS
Credential	:	M..D.
Telephone Number	:	678-705-1691

Provider Enumeration Date	:	03/11/2012
Last Update Date	:	03/11/2012

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Directions to “PORT-A-WELLNESS LLC ” Practice Location

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