Provider Demographics
NPI:1154330348
Name:EASTSIDE MEDSPA AND FAMILY PRACTICE INC.
Entity Type:Organization
Organization Name:EASTSIDE MEDSPA AND FAMILY PRACTICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-618-3133
Mailing Address - Street 1:2320 HAFLINGER CIR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-5292
Mailing Address - Country:US
Mailing Address - Phone:772-618-3133
Mailing Address - Fax:
Practice Address - Street 1:7138 HIGHWAY 212
Practice Address - Street 2:SUITE D
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-8047
Practice Address - Country:US
Practice Address - Phone:770-679-5238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057439261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
H43879Medicare UPIN