Basic Information
| Provider Information | |||||||||
| NPI: | 1518009430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLBROOK ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7229 WHEAT ST NE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300141566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786255132 | ||||||||
| FaxNumber: | 6786255137 | ||||||||
| Practice Location | |||||||||
| Address1: | 1269 WELLBROOK CIR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709220505 | ||||||||
| FaxNumber: | 6786255137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARCZUK | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6786255132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 4034 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.