Provider Demographics
NPI:1396120291
Name:BIG HART WELLNESS AND SPORTS ACADEMY
Entity type:Organization
Organization Name:BIG HART WELLNESS AND SPORTS ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGERTON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-301-4432
Mailing Address - Street 1:5991 THOMPSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-4029
Mailing Address - Country:US
Mailing Address - Phone:702-301-4432
Mailing Address - Fax:
Practice Address - Street 1:2021 W LIDDELL RD
Practice Address - Street 2:SUITE B
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8831
Practice Address - Country:US
Practice Address - Phone:702-301-4432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider OrganizationGroup - Multi-Specialty