Provider Demographics
NPI:1487041745
Name:PHYSICAL WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:PHYSICAL WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-683-2304
Mailing Address - Street 1:11877 DOUGLAS RD STE 102299
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4325
Mailing Address - Country:US
Mailing Address - Phone:888-683-2304
Mailing Address - Fax:
Practice Address - Street 1:4153 FLAT SHOALS PKWY
Practice Address - Street 2:BLDG A
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4106
Practice Address - Country:US
Practice Address - Phone:888-683-2304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty