Provider Demographics
NPI:1184283848
Name:SISTAH SPACE WOMEN'S WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:SISTAH SPACE WOMEN'S WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOMAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-451-7546
Mailing Address - Street 1:351 LAUREN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-7007
Mailing Address - Country:US
Mailing Address - Phone:312-451-7546
Mailing Address - Fax:470-250-2401
Practice Address - Street 1:130 HOWELL RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-6800
Practice Address - Country:US
Practice Address - Phone:312-451-7546
Practice Address - Fax:470-250-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service