Provider Demographics
NPI:1235871013
Name:REINVENT YOUR IDENTITY,LLC
Entity Type:Organization
Organization Name:REINVENT YOUR IDENTITY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIDEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-644-4198
Mailing Address - Street 1:4403 KADY CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4403 KADY CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-3700
Practice Address - Country:US
Practice Address - Phone:404-644-4198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health