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Vitality Ageless Center Llc 1300 Peachtree Industrial Blvd #1201 Suwanee GA 30024-4686 | |
| (770) 614-6266 | |
| (770) 623-9949 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | Vitality Ageless Center Llc, Suwanee, Georgia |
| Authorized Official Name and Position | Julie Yu (OWNER) |
| Authorized Official Contact | 7706146266 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1300 Peachtree Industrial Blvd Ste 1201 Suwanee GA 30024-4550 Ph: (770) 614-6266 | Vitality Ageless Center Llc 1300 Peachtree Industrial Blvd #1201 Suwanee GA 30024-4686 Ph: (770) 614-6266 |
| NPI Number | 1730657271 |
|---|---|
| Provider Enumeration Date | 11/02/2018 |
| Last Update Date | 05/09/2024 |
| Medicare PECOS PAC ID | 6800135872 |
|---|---|
| Medicare Enrollment ID | O20190325002304 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730657271 | NPI | - | NPPES |
| Provider Name | Jenny H Chang |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1972939130 PECOS PAC ID: 6709012958 Enrollment ID: I20131119000389 |
| Provider Name | Jeremy Erwin Garrard |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1386871895 PECOS PAC ID: 2365674645 Enrollment ID: I20150817001118 |
| Provider Name | Steve Odeh |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1801940200 PECOS PAC ID: 8820078553 Enrollment ID: I20160425001794 |
| Provider Name | Cindy Denise Oden |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124597646 PECOS PAC ID: 5294158796 Enrollment ID: I20200630002643 |
| Provider Name | Lequawn M James |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1154834406 PECOS PAC ID: 4688005598 Enrollment ID: I20201209002305 |
| Provider Name | Linda P Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093291544 PECOS PAC ID: 6204225543 Enrollment ID: I20211108002257 |
| Provider Name | Nethophah N C Simmons |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1851149314 PECOS PAC ID: 7416481510 Enrollment ID: I20241112003761 |
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