Provider Demographics
NPI:1144496662
Name:BASIC WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:BASIC WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:MASSAGE THERAPIST
Authorized Official - Phone:706-543-5755
Mailing Address - Street 1:1190 PRINCE AVE LOWR B
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2769
Mailing Address - Country:US
Mailing Address - Phone:706-208-7386
Mailing Address - Fax:
Practice Address - Street 1:1190 PRINCE AVE
Practice Address - Street 2:LOWR B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2769
Practice Address - Country:US
Practice Address - Phone:706-208-7386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty