Provider Demographics
NPI:1700134913
Name:MAX 360 HEALTH, LLC
Entity Type:Organization
Organization Name:MAX 360 HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-312-5005
Mailing Address - Street 1:12315 CRABAPPLE RD
Mailing Address - Street 2:SUITE 144
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12315 CRABAPPLE RD
Practice Address - Street 2:SUITE 144
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6329
Practice Address - Country:US
Practice Address - Phone:678-261-3222
Practice Address - Fax:678-261-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038955208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty