Provider Demographics
NPI:1417428129
Name:WELLNESS MEDICINE
Entity Type:Organization
Organization Name:WELLNESS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JELUNDER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-479-1234
Mailing Address - Street 1:990 BEAR CREEK BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1864
Mailing Address - Country:US
Mailing Address - Phone:678-479-1234
Mailing Address - Fax:678-479-5678
Practice Address - Street 1:990 BEAR CREEK BLVD STE G
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:678-479-1234
Practice Address - Fax:678-479-5678
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty