NPIMap

Organization Active NPI

Ivydale Wellness Center LLC

Doing business as Ivydale Wellness Clinic

  • Community/Behavioral Health Agency
  • Winder, GA
National Provider Identifier
1326653783
Registry record updated Sep 12, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
Legal business name
IVYDALE WELLNESS CENTER LLC
Doing business as
Ivydale Wellness Clinic
Practice address
361 Resource Pkwy
Winder, GA 30680-8364
Phone
(770) 291-0419
NPI assigned
Sep 12, 2020
Organization subpart
Yes
Parent organization
19137243As reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 12, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ablavi Adodo Agomessou, NPNPI 1164885778
Title
Pmhnp-C
Phone
(404) 819-8701

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X Primary
Primary Care Clinic/Center 261QP2300X
Geropsychiatric Psychiatric/Mental Health Clinical Nurse SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 364SP0813X

Addresses

Primary practice location

361 Resource Pkwy
Winder, GA 30680-8364

Mailing address

881 Ivydale LN
Lawrenceville, GA 30045-7818
Phone (404) 819-8701

Other names 1

  • Ivydale Wellness Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Ivydale Wellness Center LLC2 organizations share this tax ID, including this one
Part of
Ivydale Wellness Center LLC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

343 Resource Way
Winder, GA 30680
Phone (770) 291-0419

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1599868800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599868800000",
    "number": "1326653783",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "881 IVYDALE LN",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300457818",
            "telephone_number": "404-819-8701"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "361 RESOURCE PKWY",
            "city": "WINDER",
            "state": "GA",
            "postal_code": "306808364",
            "telephone_number": "770-291-0419"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVYDALE WELLNESS CENTER LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "19137243",
        "enumeration_date": "2020-09-12",
        "last_updated": "2020-09-12",
        "certification_date": "2020-09-12",
        "status": "A",
        "authorized_official_last_name": "AGOMESSOU",
        "authorized_official_first_name": "ABLAVI",
        "authorized_official_middle_name": "ADODO",
        "authorized_official_title_or_position": "PMHNP-C",
        "authorized_official_telephone_number": "404-819-8701",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "364SP0813X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Clinical Nurse Specialist, Psychiatric/Mental Health, Geropsychiatric",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ivydale Wellness Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Winder, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.