Provider Demographics
NPI:1003646902
Name:COOSA VALLEY WELLNESS, LLC
Entity type:Organization
Organization Name:COOSA VALLEY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-302-3202
Mailing Address - Street 1:4451 ALABAMA HWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9200
Mailing Address - Country:US
Mailing Address - Phone:904-302-3202
Mailing Address - Fax:706-739-7276
Practice Address - Street 1:4451 ALABAMA HWY NW STE 2
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-9200
Practice Address - Country:US
Practice Address - Phone:904-302-3202
Practice Address - Fax:706-739-7276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care