Provider Demographics
NPI:1356738447
Name:POSITIVE BALANCE WELLNESS CENTER @ BEN HILL UNITED METHODIST CHURCH
Entity type:Organization
Organization Name:POSITIVE BALANCE WELLNESS CENTER @ BEN HILL UNITED METHODIST CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-346-8264
Mailing Address - Street 1:2099 FAIRBURN RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-4812
Mailing Address - Country:US
Mailing Address - Phone:404-428-3133
Mailing Address - Fax:404-344-7810
Practice Address - Street 1:2099 FAIRBURN RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-4812
Practice Address - Country:US
Practice Address - Phone:404-428-3133
Practice Address - Fax:404-344-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036661261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000635115EMedicaid
GA2084P08000XOtherTAXONOMY
GA00635115DMedicaid
GA1285707455OtherNPI
GA26BDFPCMedicare PIN
GAG24538Medicare UPIN