Provider Demographics
NPI:1174862908
Name:MBA WELLNESS CENTERS
Entity Type:Organization
Organization Name:MBA WELLNESS CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:INDIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-4009
Mailing Address - Street 1:1233 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE C&D
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6399
Mailing Address - Country:US
Mailing Address - Phone:770-474-4009
Mailing Address - Fax:770-474-8003
Practice Address - Street 1:1233 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE C&D
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6399
Practice Address - Country:US
Practice Address - Phone:770-474-4009
Practice Address - Fax:770-474-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANTP001062261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone