MEDICARE: LODEBAR HEALTH AND WELLNESS CLINIC LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QU0200X	Urgent Care Clinic/Center
2	363LA2200X	Adult Health Nurse Practitioner
3	363LG0600X	Gerontology Nurse Practitioner
4	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1871399212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LODEBAR HEALTH AND WELLNESS CLINIC LLC

Provider Business Mailing Address
First Line	:	2945 STONE HOGAN CONNECTOR RD SW STE 205
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2839
Country	:	US
Telephone Number	:	404-343-1846
Fax Number	:

Provider Business Practice Location Address
First Line	:	2945 STONE HOGAN CONNECTOR RD SW STE 205
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2839
Country	:	US
Telephone Number	:	229-234-9695
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	EMMANUELA C CONSEILLANT
Credential	:	NP-BC
Telephone Number	:	229-234-9695

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	02/24/2025

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