MEDICARE: OPTIWELL MD DULUTH 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	132700000X	Dietary Manager	61722	GA

General Provider Information

NPI Number	:	1285017889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIWELL MD DULUTH LLC

Provider Business Mailing Address
First Line	:	8770 COLONIAL PL
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-6641
Country	:	US
Telephone Number	:	404-202-9433
Fax Number	:	800-845-0290

Provider Business Practice Location Address
First Line	:	4300 PLEASANT HILL RD
Second Line	:	SUITE A
City	:	DULUTH
State	:	GA
Zip	:	30096-6379
Country	:	US
Telephone Number	:	678-682-8734
Fax Number	:	678-682-8736

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARY BELL FEDERICO
Credential	:
Telephone Number	:	404-202-9433

Provider Enumeration Date	:	07/01/2015
Last Update Date	:	07/01/2015

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