Provider Demographics
NPI:1073041166
Name:WILSON'S WELLNESS CLINICAL CARE, LLC
Entity Type:Organization
Organization Name:WILSON'S WELLNESS CLINICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-981-3936
Mailing Address - Street 1:7435 CRESCENT BEND CV
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6207
Mailing Address - Country:US
Mailing Address - Phone:1404-396-2754
Mailing Address - Fax:404-393-4038
Practice Address - Street 1:14B PROFESSIONAL CT SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2832
Practice Address - Country:US
Practice Address - Phone:404-981-3936
Practice Address - Fax:404-393-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care