Provider Demographics
NPI:1346307048
Name:EAST METRO WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:EAST METRO WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-922-7282
Mailing Address - Street 1:PO BOX 83363
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9444
Mailing Address - Country:US
Mailing Address - Phone:770-922-7282
Mailing Address - Fax:770-922-7843
Practice Address - Street 1:1289 PARKER RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5957
Practice Address - Country:US
Practice Address - Phone:770-922-7282
Practice Address - Fax:770-922-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU32759Medicare UPIN
GA35ZCJJPMedicare ID - Type UnspecifiedMEDICARE PERF PROV #
GAGRP7357Medicare ID - Type UnspecifiedMEDICARE GROUP #