Provider Demographics
NPI:1275782245
Name:ELISIVE QUALITY
Entity Type:Organization
Organization Name:ELISIVE QUALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:SUARES
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-580-1041
Mailing Address - Street 1:925B PEACHTREE ST NE # 131
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3918
Mailing Address - Country:US
Mailing Address - Phone:404-580-1041
Mailing Address - Fax:
Practice Address - Street 1:925B PEACHTREE ST NE # 131
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3918
Practice Address - Country:US
Practice Address - Phone:404-580-1041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty