Provider Demographics
NPI:1790307924
Name:CRYOGEN PLUS LLC
Entity Type:Organization
Organization Name:CRYOGEN PLUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYNISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASTREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-428-2139
Mailing Address - Street 1:461 SANDY CREEK RD STE 41262
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4290
Mailing Address - Country:US
Mailing Address - Phone:267-973-3005
Mailing Address - Fax:
Practice Address - Street 1:1039 GRANT ST SE BLDG A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-2014
Practice Address - Country:US
Practice Address - Phone:470-428-2139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20190026OtherLICENSE