Provider Demographics
NPI:1386878759
Name:HERITAGE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:HERITAGE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-879-9019
Mailing Address - Street 1:3568 OLD MILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4464
Mailing Address - Country:US
Mailing Address - Phone:678-879-9019
Mailing Address - Fax:678-879-9021
Practice Address - Street 1:3568 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4464
Practice Address - Country:US
Practice Address - Phone:678-879-9019
Practice Address - Fax:678-879-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty