Provider Demographics
NPI:1124243704
Name:WELLNESS ONE OF SUWANEE
Entity type:Organization
Organization Name:WELLNESS ONE OF SUWANEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-850-0857
Mailing Address - Street 1:PO BOX 672641
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30006-2641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:678-482-7375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO008139111N00000X
GA052963207Q00000X
GA042114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty