Provider Demographics
NPI:1497133789
Name:NEW IMAGE MEDICAL AESTHETIC AND WELLNESS
Entity Type:Organization
Organization Name:NEW IMAGE MEDICAL AESTHETIC AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:ZENGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-769-5757
Mailing Address - Street 1:2 S MAIN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7101
Mailing Address - Country:US
Mailing Address - Phone:706-769-5757
Mailing Address - Fax:
Practice Address - Street 1:2 S MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7101
Practice Address - Country:US
Practice Address - Phone:706-769-5757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37738207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty