Provider Demographics
NPI:1841622925
Name:THE 90 GROUP, LLC
Entity type:Organization
Organization Name:THE 90 GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ELLIS-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:QDCP
Authorized Official - Phone:770-790-0012
Mailing Address - Street 1:1800 PHOENIX BLVD BLDG 400
Mailing Address - Street 2:SUITE 400 #16
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:770-790-0012
Mailing Address - Fax:866-205-6289
Practice Address - Street 1:1800 PHOENIX BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5560
Practice Address - Country:US
Practice Address - Phone:770-790-0012
Practice Address - Fax:866-205-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA110-R-1162251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health