Provider Demographics
NPI:1164177085
Name:SOUTH FORSYTH WELLNESS LLC
Entity Type:Organization
Organization Name:SOUTH FORSYTH WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIFABIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-203-3998
Mailing Address - Street 1:411 JASMINE CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-7716
Mailing Address - Country:US
Mailing Address - Phone:770-203-3998
Mailing Address - Fax:
Practice Address - Street 1:6110 MCFARLAND STATION DR STE 1103
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6801
Practice Address - Country:US
Practice Address - Phone:770-203-3998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty