Provider Demographics
NPI:1285017889
Name:OPTIWELL MD DULUTH LLC
Entity Type:Organization
Organization Name:OPTIWELL MD DULUTH LLC
Other - Org Name:OPTIWELL MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BELL
Authorized Official - Last Name:FEDERICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-202-9433
Mailing Address - Street 1:8770 COLONIAL PL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-6641
Mailing Address - Country:US
Mailing Address - Phone:404-202-9433
Mailing Address - Fax:800-845-0290
Practice Address - Street 1:4300 PLEASANT HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6379
Practice Address - Country:US
Practice Address - Phone:678-682-8734
Practice Address - Fax:678-682-8736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61722132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty