Provider Demographics
NPI:1891011516
Name:CENTER FOR WELLNESS AND PREVENTATIVE MEDICINE
Entity Type:Organization
Organization Name:CENTER FOR WELLNESS AND PREVENTATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-352-1234
Mailing Address - Street 1:3 JOHNSTON STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-352-1234
Mailing Address - Fax:912-352-0492
Practice Address - Street 1:3 JOHNSTON STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-352-1234
Practice Address - Fax:912-352-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055437305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization