Provider Demographics
NPI:1750615464
Name:MEDIWELLNESS, LLC
Entity type:Organization
Organization Name:MEDIWELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-531-9692
Mailing Address - Street 1:2227 IDLEWOOD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4827
Mailing Address - Country:US
Mailing Address - Phone:678-531-9692
Mailing Address - Fax:
Practice Address - Street 1:2227 IDLEWOOD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4827
Practice Address - Country:US
Practice Address - Phone:678-531-9692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty