Provider Demographics
NPI:1316392541
Name:FOURTH AND BEECH, INC.
Entity Type:Organization
Organization Name:FOURTH AND BEECH, INC.
Other - Org Name:MEDI-WEIGHTLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IKUSUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-229-9048
Mailing Address - Street 1:5024 VERNON SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4653
Mailing Address - Country:US
Mailing Address - Phone:404-229-9048
Mailing Address - Fax:
Practice Address - Street 1:5475 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4114
Practice Address - Country:US
Practice Address - Phone:678-379-1300
Practice Address - Fax:678-802-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004684133V00000X
GA56363207Q00000X
GARN108447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty