Provider Demographics
NPI:1427276617
Name:KENNESAW HEALTH AND WELLNESS
Entity type:Organization
Organization Name:KENNESAW HEALTH AND WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-423-1799
Mailing Address - Street 1:2241 LEWIS ST NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2714
Mailing Address - Country:US
Mailing Address - Phone:770-423-1799
Mailing Address - Fax:678-213-1529
Practice Address - Street 1:2241 LEWIS ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2714
Practice Address - Country:US
Practice Address - Phone:770-423-1799
Practice Address - Fax:678-213-1529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJDPMedicare ID - Type Unspecified