Provider Demographics
NPI:1740987379
Name:WEST GEORGIA WELLNESS CENTER LLC
Entity type:Organization
Organization Name:WEST GEORGIA WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-480-9853
Mailing Address - Street 1:2102 KENDALL CLOSE NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 ENTERPRISE PATH STE 104B
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2655
Practice Address - Country:US
Practice Address - Phone:609-480-9853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility