Provider Demographics
NPI:1669522959
Name:WISTERIA WELLNESS CENTER, INC.
Entity type:Organization
Organization Name:WISTERIA WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-979-0074
Mailing Address - Street 1:2336 WISTERIA DR STE 410
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6160
Mailing Address - Country:US
Mailing Address - Phone:770-979-0074
Mailing Address - Fax:770-979-8305
Practice Address - Street 1:2336 WISTERIA DR STE 410
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6160
Practice Address - Country:US
Practice Address - Phone:770-979-0074
Practice Address - Fax:770-979-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty