Organization
IVYDALE WELLNESS CENTER LLC
Active
Parent organization
19137243
Other names
Ivydale Wellness Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
19137243
Authorized official
DR. ABLAVI ADODO AGOMESSOU NP (PMHNP-C)
(404) 819-8701
Entity
Organization
Contact information
Practice address
361 RESOURCE PKWY, WINDER, GA 30680-8364
(770) 291-0419
Mailing address
881 IVYDALE LN, LAWRENCEVILLE, GA 30045-7818
(404) 819-8701
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
261QP2300X
Primary Care Clinic/Center
—
—
364SP0813X
Geropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
—
—
Other
Enumeration date
09/12/2020
Last updated
09/12/2020
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