Provider Demographics
NPI:1780448670
Name:CENTER FOR INTENTIONAL WELLNESS, LLC
Entity type:Organization
Organization Name:CENTER FOR INTENTIONAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:229-395-8243
Mailing Address - Street 1:3295 RIVER EXCHANGE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4221
Mailing Address - Country:US
Mailing Address - Phone:229-395-8243
Mailing Address - Fax:678-550-6860
Practice Address - Street 1:3295 RIVER EXCHANGE DR STE 400
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4221
Practice Address - Country:US
Practice Address - Phone:229-395-8243
Practice Address - Fax:678-550-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty