Provider Demographics
NPI:1952914368
Name:HARDY RENEW WELLNESS,LLC
Entity Type:Organization
Organization Name:HARDY RENEW WELLNESS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-734-6621
Mailing Address - Street 1:1430 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-4329
Mailing Address - Country:US
Mailing Address - Phone:212-734-6621
Mailing Address - Fax:
Practice Address - Street 1:838 CANNON RUN SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4600
Practice Address - Country:US
Practice Address - Phone:423-443-9956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1629053277OtherNPI