Provider Demographics
NPI:1124364534
Name:WELLNESS CENTER OF VALDOSTA
Entity Type:Organization
Organization Name:WELLNESS CENTER OF VALDOSTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NILAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-269-4250
Mailing Address - Street 1:206 E ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-4508
Mailing Address - Country:US
Mailing Address - Phone:229-269-4250
Mailing Address - Fax:229-269-4521
Practice Address - Street 1:206 E ADAIR ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-4508
Practice Address - Country:US
Practice Address - Phone:229-269-4250
Practice Address - Fax:229-269-4521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9760305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service