# LILAC WELLNESS AND SPA LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lilac Wellness and Spa
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750075776
- **Authorized official:** LOLA OGUNNIYI (PRESIDENT)
- **Authorized official phone:** (404) 725-8455

## Contact information

- **Practice address:** 1841 MONTREAL RD STE 111, TUCKER, GA 30084-5712
- **Practice address phone:** (470) 871-9105
- **Mailing address:** 3050 FIVE FORKS TRICKUM RD SW STE D454, LILBURN, GA 30047-1810
- **Mailing address phone:** (470) 871-9105

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 163W00000X | Registered Nurse | — | NULL | — |
| 163W00000X | Registered Nurse | — | — | — |
| 163WI0500X | Infusion Therapy Registered Nurse | — | NULL | — |
| 163WI0500X | Infusion Therapy Registered Nurse | — | — | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 06/05/2023
- **Last updated:** 02/28/2024