Provider Demographics
NPI:1336447754
Name:ALPHA NUTRITION & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ALPHA NUTRITION & WELLNESS CENTER, LLC
Other - Org Name:ALPHA CONSULTING & WELLNESS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:ORIAKO
Authorized Official - Last Name:OKWOCHE-WELSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:800-634-1843
Mailing Address - Street 1:5 OLD ROSWELL ST
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-7907
Mailing Address - Country:US
Mailing Address - Phone:800-634-1843
Mailing Address - Fax:678-701-5604
Practice Address - Street 1:5 OLD ROSWELL ST
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-7907
Practice Address - Country:US
Practice Address - Phone:800-634-1843
Practice Address - Fax:678-701-5604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D2005794293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D2005794OtherCLIA