Provider Demographics
NPI:1184039935
Name:NORTH GEORGIA NUTRITION AND WELLNESS LLC
Entity Type:Organization
Organization Name:NORTH GEORGIA NUTRITION AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-718-6736
Mailing Address - Street 1:2709 LEGISLATIVE LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8037
Mailing Address - Country:US
Mailing Address - Phone:770-718-6736
Mailing Address - Fax:
Practice Address - Street 1:3617 BRASELTON HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4667
Practice Address - Country:US
Practice Address - Phone:770-718-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty