Provider Demographics
NPI:1851035778
Name:COLORECTAL WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:COLORECTAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KING-MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-473-3237
Mailing Address - Street 1:5829 CAMPBELLTON RD SW STE 104-128
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8037
Mailing Address - Country:US
Mailing Address - Phone:770-325-2275
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W STE 500B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4556
Practice Address - Country:US
Practice Address - Phone:770-325-2275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty