MEDICARE: BEYOND YOUR ORDINARY, INC.

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	251S00000X	Community/Behavioral Health Agency
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1396365094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEYOND YOUR ORDINARY, INC.

Provider Business Mailing Address
First Line	:	97 ATLANTA ST STE 100
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-2192
Country	:	US
Telephone Number	:	336-268-6469
Fax Number	:

Provider Business Practice Location Address
First Line	:	97 ATLANTA ST STE 100
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-2192
Country	:	US
Telephone Number	:	336-268-6469
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MYA CULLINS
Credential	:	MS, MAT SPECIALIST
Telephone Number	:	336-268-6469

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	08/12/2020

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