MEDICARE: RENEW WELLNESS GROUP, 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	101YP2500X	Professional Counselor	LPC006062	GA

General Provider Information

NPI Number	:	1174004881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW WELLNESS GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 42775
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-0775
Country	:	US
Telephone Number	:	404-965-5848
Fax Number	:	404-965-5848

Provider Business Practice Location Address
First Line	:	3915 CASCADE RD SW STE T-145
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8520
Country	:	US
Telephone Number	:	404-965-5848
Fax Number	:	404-965-5848

Authorized Official
Title or Position	:	OWNER
Name	:	SARAH NYASHA PACE
Credential	:	LPC
Telephone Number	:	404-909-4507

Provider Enumeration Date	:	08/22/2018
Last Update Date	:	10/20/2022

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