Provider Demographics
NPI:1649677626
Name:WONDERFULLY MADE WELLNESS, INC.
Entity type:Organization
Organization Name:WONDERFULLY MADE WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:QURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ACSM-HFS
Authorized Official - Phone:770-853-3216
Mailing Address - Street 1:464 VININGS VINTAGE CIRCLE SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:464 VININGS VINTAGE CIRCLE SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:770-853-3216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WONDERFULLY MADE HEALTH & FITNESS SOLUTIONS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty