Provider Demographics
NPI:1275781759
Name:CLJ HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CLJ HEALTHCARE, LLC
Other - Org Name:OPULENCE AESTHETIC MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEDRA
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:DODDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-591-3429
Mailing Address - Street 1:6572 HIGHWAY 92
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7562
Mailing Address - Country:US
Mailing Address - Phone:770-591-3429
Mailing Address - Fax:
Practice Address - Street 1:6572 HIGHWAY 92
Practice Address - Street 2:SUITE 200
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-7562
Practice Address - Country:US
Practice Address - Phone:770-591-3429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039170208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF94272Medicare PIN