Provider Demographics
NPI:1003513524
Name:EARTH BAR LLC
Entity Type:Organization
Organization Name:EARTH BAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UNIQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:CHHP
Authorized Official - Phone:706-941-2302
Mailing Address - Street 1:2855 TOBACCO RD STE D
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7197
Mailing Address - Country:US
Mailing Address - Phone:706-941-2302
Mailing Address - Fax:
Practice Address - Street 1:2855 TOBACCO RD STE D
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-7197
Practice Address - Country:US
Practice Address - Phone:706-941-2302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty