Provider Demographics
NPI:1902163991
Name:PATHWAY TO WELLNESS CENTER PC
Entity Type:Organization
Organization Name:PATHWAY TO WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IMO
Authorized Official - Middle Name:F
Authorized Official - Last Name:NDEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MPH
Authorized Official - Phone:706-228-2929
Mailing Address - Street 1:4111 OLD PETERSBURG RD
Mailing Address - Street 2:4111 OLD PETERSBURG RD
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3346
Mailing Address - Country:US
Mailing Address - Phone:706-228-2929
Mailing Address - Fax:
Practice Address - Street 1:4111 OLD PETERSBURG RD
Practice Address - Street 2:4111 OLD PETERSBURG RD
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-3346
Practice Address - Country:US
Practice Address - Phone:706-228-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0609682083P0901X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty