Provider Demographics
NPI:1215580253
Name:ALZNNER 113 WALKING CENTER INC
Entity Type:Organization
Organization Name:ALZNNER 113 WALKING CENTER INC
Other - Org Name:SUNNYWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUNAE
Authorized Official - Middle Name:HYUN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:470-733-9177
Mailing Address - Street 1:2550 PLEASANT HILL RD STE 106
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4153
Mailing Address - Country:US
Mailing Address - Phone:470-733-9177
Mailing Address - Fax:
Practice Address - Street 1:2550 PLEASANT HILL RD STE 106
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4153
Practice Address - Country:US
Practice Address - Phone:470-733-9177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-18
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1215580253Medicaid