Provider Demographics
NPI:1891859849
Name:BREMEN FAMILY HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:BREMEN FAMILY HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEMPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-537-5555
Mailing Address - Street 1:509 ALABAMA AVE S
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-2007
Mailing Address - Country:US
Mailing Address - Phone:770-537-5555
Mailing Address - Fax:770-537-0548
Practice Address - Street 1:509 ALABAMA AVE S
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2007
Practice Address - Country:US
Practice Address - Phone:770-537-5555
Practice Address - Fax:770-537-0548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2627111N00000X
GA204C00000X
332B00000X
GARN150905364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6710890001Medicare NSC