Provider Demographics
NPI:1124291927
Name:WELLNESS PRIMARY CARE, LLC
Entity type:Organization
Organization Name:WELLNESS PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:HUY-DAO
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:678-380-9889
Mailing Address - Street 1:5456 JIMMY CARTER BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1511
Mailing Address - Country:US
Mailing Address - Phone:678-380-9889
Mailing Address - Fax:
Practice Address - Street 1:5456 JIMMY CARTER BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1511
Practice Address - Country:US
Practice Address - Phone:678-380-9889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047813171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000884793CMedicaid
GAH19592OtherUPIN
GAGRP6225OtherMEDICARE GROUP NO.
GA11BDXHBMedicare PIN