Provider Demographics
NPI:1427648765
Name:UNIVERSAL WELLNESS LLC
Entity type:Organization
Organization Name:UNIVERSAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-302-2419
Mailing Address - Street 1:1824 OLD DOGWOOD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-7515
Mailing Address - Country:US
Mailing Address - Phone:843-302-2419
Mailing Address - Fax:
Practice Address - Street 1:1824 OLD DOGWOOD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-7515
Practice Address - Country:US
Practice Address - Phone:843-302-2419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health