Provider Demographics
NPI:1689798811
Name:PROSPORT WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PROSPORT WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-454-8300
Mailing Address - Street 1:5464 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-454-8300
Mailing Address - Fax:770-986-9962
Practice Address - Street 1:2000 POWERS FERRY RD.
Practice Address - Street 2:SUITE A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067
Practice Address - Country:US
Practice Address - Phone:770-454-8300
Practice Address - Fax:770-986-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005750111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty