| Organization Name: | PHOENIX WELLNESS CENTER LLC |
| NPI Number: | 1316135643 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | FABIAN CENTENO (PRESIDENT) |
| Mailing Address: | 142 Mitchell St Sw Suite 200 Atlanta |
| State: | GA US |
| Postal Code: | 303033439 |
| Phone Number: | 4045842105 |
| Fax Number: | 4045842106 |
| NPI Enumeration Date: | 10/11/2007 |
| NPI Last Update Date: | 10/11/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
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Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |