Provider Demographics
NPI:1487362919
Name:MAXX LIFE HEALTH CARE LLC
Entity type:Organization
Organization Name:MAXX LIFE HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-932-7183
Mailing Address - Street 1:1540 PENNSYLVANIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9112
Mailing Address - Country:US
Mailing Address - Phone:404-932-7183
Mailing Address - Fax:
Practice Address - Street 1:1540 PENNSYLVANIA AVE STE B
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9112
Practice Address - Country:US
Practice Address - Phone:404-932-7183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty