MEDICARE: ASILI WELLNESS

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1326683517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASILI WELLNESS

Provider Business Mailing Address
First Line	:	PO BOX 1461
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30085-1461
Country	:	US
Telephone Number	:	678-404-1077
Fax Number	:

Provider Business Practice Location Address
First Line	:	4325 1ST AVE # 1461
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-4498
Country	:	US
Telephone Number	:	678-404-1077
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE WARE SPENCER
Credential	:
Telephone Number	:	678-404-1077

Provider Enumeration Date	:	11/12/2019
Last Update Date	:	12/20/2021

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Directions to “ASILI WELLNESS ” Practice Location

Language	Start Address	Practice Location

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