Provider Demographics
NPI:1407328776
Name:ACTIVATE YOUR HEALTH NUTRITION, LLC
Entity Type:Organization
Organization Name:ACTIVATE YOUR HEALTH NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MECCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-379-7882
Mailing Address - Street 1:241 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 WOODSTOCK RD STE 7100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5632
Practice Address - Country:US
Practice Address - Phone:678-379-7882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-26
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD003790OtherLICENSURE