Provider Demographics
NPI:1578843256
Name:MEDPRIME, LLC
Entity Type:Organization
Organization Name:MEDPRIME, LLC
Other - Org Name:WELLNESS PLUS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-652-3667
Mailing Address - Street 1:PO BOX 501741
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31150-1741
Mailing Address - Country:US
Mailing Address - Phone:404-522-5552
Mailing Address - Fax:404-522-5151
Practice Address - Street 1:4651 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6339
Practice Address - Country:US
Practice Address - Phone:404-522-5552
Practice Address - Fax:404-522-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07312111N00000X
GA044023208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty