Provider Demographics
NPI:1306019674
Name:WELLPOINT ACUPUNCTURE, INC
Entity Type:Organization
Organization Name:WELLPOINT ACUPUNCTURE, INC
Other - Org Name:WELLPOINT PHYSICAL THERAPY & ACUPUNCTURE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, LAC
Authorized Official - Phone:404-444-7160
Mailing Address - Street 1:372 SOUTHERLAND TER NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2346
Mailing Address - Country:US
Mailing Address - Phone:404-444-7160
Mailing Address - Fax:
Practice Address - Street 1:372 SOUTHERLAND TER NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-2346
Practice Address - Country:US
Practice Address - Phone:404-444-7160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117171100000X
GA7706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6810Medicare PIN