MEDICARE: CHATTAHOOCHEE INSTITUTE FOR WELLNESS, LONGEVITY & WEIGHT MANAGEMENT

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	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1770366049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHATTAHOOCHEE INSTITUTE FOR WELLNESS, LONGEVITY & WEIGHT MANAGEMENT

Provider Business Mailing Address
First Line	:	110 ENTERPRISE CT STE B
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-9231
Country	:	US
Telephone Number	:	706-887-7790
Fax Number	:	706-507-0016

Provider Business Practice Location Address
First Line	:	110 ENTERPRISE CT STE B
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-9231
Country	:	US
Telephone Number	:	706-507-0001
Fax Number	:	706-507-0016

Authorized Official
Title or Position	:	MD
Name	:	BANTWAL SURESH BALIGA
Credential	:
Telephone Number	:	706-718-9556

Provider Enumeration Date	:	08/18/2023
Last Update Date	:	09/28/2023

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