| Organization Name: | PORT-A-WELLNESS LLC |
| NPI Number: | 1063787901 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RAMONA ANN MINNIS (MEDICAL DIRECTOR) |
| Mailing Address: | 1670 Washington Ave East Point |
| State: | GA US |
| Postal Code: | 303444248 |
| Phone Number: | 6787051691 |
| Fax Number: | 8552897475 |
| NPI Enumeration Date: | 03/11/2012 |
| NPI Last Update Date: | 03/11/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 042668 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |