Provider Demographics
NPI:1659869626
Name:I.M. WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:I.M. WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, MAC, ICADC-II
Authorized Official - Phone:770-990-2453
Mailing Address - Street 1:1057 REDHEAD CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4473
Mailing Address - Country:US
Mailing Address - Phone:770-990-2453
Mailing Address - Fax:
Practice Address - Street 1:120 MLK SR HERITAGE TRL STE 110
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3411
Practice Address - Country:US
Practice Address - Phone:770-990-2453
Practice Address - Fax:706-553-8306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009820261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health