Provider Demographics
NPI:1043716392
Name:BROOKHAVEN AESTHESTIC INSTITUTE
Entity Type:Organization
Organization Name:BROOKHAVEN AESTHESTIC INSTITUTE
Other - Org Name:REDDY RECONSTRUCTIVE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PULI
Authorized Official - Middle Name:PRAVIN
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-754-1994
Mailing Address - Street 1:3535 PEACHTREE RD NE STE 520-631
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3287
Mailing Address - Country:US
Mailing Address - Phone:404-481-5089
Mailing Address - Fax:404-795-0461
Practice Address - Street 1:1418 DRESDEN DR NE STE 120
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319
Practice Address - Country:US
Practice Address - Phone:404-481-5089
Practice Address - Fax:404-795-0461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46220208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty