Provider Demographics
NPI:1750075776
Name:LILAC WELLNESS AND SPA LLC
Entity type:Organization
Organization Name:LILAC WELLNESS AND SPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNNIYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-725-8455
Mailing Address - Street 1:3050 FIVE FORKS TRICKUM RD SW STE D454
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1810
Mailing Address - Country:US
Mailing Address - Phone:470-871-9105
Mailing Address - Fax:
Practice Address - Street 1:1841 MONTREAL RD STE 111
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5712
Practice Address - Country:US
Practice Address - Phone:470-871-9105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty