1619000312 NPI number — WOMENS HEALTHCARE AND AESTHETICS

Table of content: (NPI 1619000312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619000312 NPI number — WOMENS HEALTHCARE AND AESTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOMENS HEALTHCARE AND AESTHETICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619000312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1403 MANCHESTER DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30012-3879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-760-8484
Provider Business Mailing Address Fax Number:
770-760-7664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5910 HILLANDALE DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-1878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-760-8484
Provider Business Practice Location Address Fax Number:
770-760-7664
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCMULLEN
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
770-760-8484

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  035507 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 393403 . This is a "BC BS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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