Provider Demographics
NPI:1568085587
Name:EIGHTY HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:EIGHTY HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:678-200-4785
Mailing Address - Street 1:4850 SUGARLOAF PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2859
Mailing Address - Country:US
Mailing Address - Phone:678-200-4785
Mailing Address - Fax:
Practice Address - Street 1:483 UPPER RIVERDALE RD SW STE G
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2579
Practice Address - Country:US
Practice Address - Phone:678-200-4785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service