Provider Demographics
NPI:1821731753
Name:IDEAL BODY INSTITUTE HUDSON ASC LLC
Entity Type:Organization
Organization Name:IDEAL BODY INSTITUTE HUDSON ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:IBIKUNLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-466-6760
Mailing Address - Street 1:367 ATHENS HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2207
Mailing Address - Country:US
Mailing Address - Phone:678-466-6760
Mailing Address - Fax:
Practice Address - Street 1:14012 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1165
Practice Address - Country:US
Practice Address - Phone:678-466-6760
Practice Address - Fax:678-802-7094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical