Provider Demographics
NPI:1871120659
Name:BRAIN AND SOUL WELLNESS GROUP, LLC
Entity type:Organization
Organization Name:BRAIN AND SOUL WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:MALOA
Authorized Official - Middle Name:CHU
Authorized Official - Last Name:AFFUEMBEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-436-0677
Mailing Address - Street 1:3050 FIVE FORKS TRICKUM RD SW STE D451
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3050 FIVE FORKS TRICKUM RD SW STE D451
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1810
Practice Address - Country:US
Practice Address - Phone:214-280-0848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-24
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty