Provider Demographics
NPI:1134982937
Name:MD WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:MD WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMAN
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:DINAVAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA, FACP
Authorized Official - Phone:404-217-9818
Mailing Address - Street 1:3505 LASSITER FALLS DR NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-4199
Mailing Address - Country:US
Mailing Address - Phone:404-217-9818
Mailing Address - Fax:
Practice Address - Street 1:1124 N TENNESSEE ST STE 103
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-7938
Practice Address - Country:US
Practice Address - Phone:404-217-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service