Provider Demographics
NPI:1588008965
Name:JAS MEDICAL & WELLNESS CENTER OF GEORGIA LLC
Entity Type:Organization
Organization Name:JAS MEDICAL & WELLNESS CENTER OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:770-940-4975
Mailing Address - Street 1:1075 WHITLOCK AVE SW
Mailing Address - Street 2:SUITE I
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1941
Mailing Address - Country:US
Mailing Address - Phone:678-797-1104
Mailing Address - Fax:
Practice Address - Street 1:1075 WHITLOCK AVE SW
Practice Address - Street 2:SUITE I
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1941
Practice Address - Country:US
Practice Address - Phone:678-797-1104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty