Provider Demographics
NPI:1366800534
Name:AGEWELL REHAB AND FITNESS, LLC
Entity type:Organization
Organization Name:AGEWELL REHAB AND FITNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-823-8157
Mailing Address - Street 1:4060 INVERNESS XING
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4781
Mailing Address - Country:US
Mailing Address - Phone:404-823-8157
Mailing Address - Fax:888-877-6415
Practice Address - Street 1:4060 INVERNESS XING
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4781
Practice Address - Country:US
Practice Address - Phone:404-823-8157
Practice Address - Fax:888-877-6415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005195261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation