Provider Demographics
NPI:1922794676
Name:PROFOUND WELLNESS
Entity Type:Organization
Organization Name:PROFOUND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AREIGNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:OMT, LMT, BCTMB
Authorized Official - Phone:470-323-6020
Mailing Address - Street 1:3954 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1894
Mailing Address - Country:US
Mailing Address - Phone:470-573-7384
Mailing Address - Fax:877-519-1412
Practice Address - Street 1:4855 RIVER GREEN PKWY STE 320
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8337
Practice Address - Country:US
Practice Address - Phone:470-323-7665
Practice Address - Fax:877-519-1412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1467855924Medicaid
GA1922794676Medicaid