Provider Demographics
NPI:1508563651
Name:INNER VOYAGE WELLNESS CENTER
Entity Type:Organization
Organization Name:INNER VOYAGE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-713-4280
Mailing Address - Street 1:603 REDCOAT CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5888
Mailing Address - Country:US
Mailing Address - Phone:404-713-4280
Mailing Address - Fax:
Practice Address - Street 1:603 REDCOAT CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5888
Practice Address - Country:US
Practice Address - Phone:404-713-4280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty