Provider Demographics
NPI:1316135643
Name:PHOENIX WELLNESS CENTER LLC
Entity type:Organization
Organization Name:PHOENIX WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CENTENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-584-2105
Mailing Address - Street 1:142 MITCHELL ST SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3439
Mailing Address - Country:US
Mailing Address - Phone:404-584-2105
Mailing Address - Fax:404-584-2106
Practice Address - Street 1:142 MITCHELL ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3439
Practice Address - Country:US
Practice Address - Phone:404-584-2105
Practice Address - Fax:404-584-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty