Provider Demographics
NPI:1912299181
Name:ATLANTA LUXURY MEDICINE AND AESTHETICS
Entity Type:Organization
Organization Name:ATLANTA LUXURY MEDICINE AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-664-7547
Mailing Address - Street 1:2880 MONTVIEW DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-5152
Mailing Address - Country:US
Mailing Address - Phone:404-664-7547
Mailing Address - Fax:
Practice Address - Street 1:191 PEACHTREE ST
Practice Address - Street 2:SUITE 3300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1740
Practice Address - Country:US
Practice Address - Phone:404-946-1815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55463207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty