Provider Demographics
NPI:1164148755
Name:ANNUAL MEDICARE WELLNESS EXAMS
Entity Type:Organization
Organization Name:ANNUAL MEDICARE WELLNESS EXAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:706-761-6553
Mailing Address - Street 1:1025 CAMPBELL PINE TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4306
Mailing Address - Country:US
Mailing Address - Phone:706-761-6553
Mailing Address - Fax:
Practice Address - Street 1:1880 BRASELTON HWY STE 118
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2877
Practice Address - Country:US
Practice Address - Phone:706-761-6553
Practice Address - Fax:678-804-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service