| Vitality Ageless Center LLC | |
|
Vitality Ageless Center Llc 1300 Peachtree Industrial Blvd #1201 Suwanee GA 30024-4686 | |
| (770) 614-6266 | |
| (770) 623-9949 |
| Full Name | Vitality Ageless Center LLC |
|---|---|
| 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 |
|---|---|
| Vitality Ageless Center LLC 1300 Peachtree Industrial Blvd Ste 1201 Suwanee GA 30024-4550 Ph: (770) 614-6266 | Vitality Ageless Center LLC 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 |
| Certification Date | 05/09/2024 |
| Medicare PECOS PAC ID | 6800135872 |
|---|---|
| Medicare Enrollment ID | O20190325002304 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730657271 | NPI | - | NPPES |
| Provider Name | Candace M Tillman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1871865113 PECOS PAC ID: 5597901470 Enrollment ID: I20130419000241 |
| 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 | Janssen Williams |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1568548790 PECOS PAC ID: 9133279698 Enrollment ID: I20160408001038 |
| Provider Name | Steve O Odeh |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1801940200 PECOS PAC ID: 8820078553 Enrollment ID: I20160425001794 |
| Provider Name | Lequawn 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 | Delli Dorne |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598372518 PECOS PAC ID: 3678797891 Enrollment ID: I20220503000260 |
| Provider Name | Karen Felicia Stephens-vasser |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1790427631 PECOS PAC ID: 7416391842 Enrollment ID: I20240214000202 |
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