Provider Demographics
NPI:1700171485
Name:INTERNAL MEDICINE & WELLNESS CENTER OF GA LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & WELLNESS CENTER OF GA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAIWANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN-BOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-586-0017
Mailing Address - Street 1:4 SAVANNAH ST
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2480
Mailing Address - Country:US
Mailing Address - Phone:770-586-0017
Mailing Address - Fax:770-586-5460
Practice Address - Street 1:4 SAVANNAH ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2480
Practice Address - Country:US
Practice Address - Phone:770-586-0017
Practice Address - Fax:770-586-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty