MEDICARE: MENOVATIONS 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

General Provider Information

NPI Number	:	1588232078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENOVATIONS WELLNESS LLC.

Provider Business Mailing Address
First Line	:	1963 WESTOVER LN NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30152-4254
Country	:	US
Telephone Number	:	404-990-2238
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 E CUMBERLAND AVE STE 201H
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-4231
Country	:	US
Telephone Number	:	813-938-6615
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. JOHN SIMUEL BEASLEY III
Credential	:	NP
Telephone Number	:	813-474-7122

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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