Provider Demographics
NPI:1861802985
Name:ADVANCED HEALTH WELLNESS & REHAB
Entity type:Organization
Organization Name:ADVANCED HEALTH WELLNESS & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-938-7542
Mailing Address - Street 1:1867 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1867 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5729
Practice Address - Country:US
Practice Address - Phone:404-600-5624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty