Provider Demographics
NPI:1255977435
Name:PREMIER WELLNESS SOLUTIONS, LLC
Entity type:Organization
Organization Name:PREMIER WELLNESS SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:404-735-0857
Mailing Address - Street 1:2716 BROOK PARK WAY
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1841 MONTREAL RD STE 110
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5713
Practice Address - Country:US
Practice Address - Phone:404-735-0857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104014125OtherNPI
1740478734OtherNPI
1366630345OtherNPI