MEDICARE: WEST GEORGIA WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	323P00000X	Psychiatric Residential Treatment Facility
2	261QM0850X	Adult Mental Health Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility
4	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1740987379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST GEORGIA WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	51 SAGEMONT CT
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-2620
Country	:	US
Telephone Number	:	770-309-9417
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 ENTERPRISE PATH STE 104B
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2655
Country	:	US
Telephone Number	:	609-480-9853
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	ANDREW WIDOTA
Credential	:
Telephone Number	:	609-480-9853

Provider Enumeration Date	:	02/14/2023
Last Update Date	:	01/08/2026

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