Basic Information
| Provider Information | |||||||||
| NPI: | 1457563447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER IMAGE COSMETIC & LASER SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4553 N SHALLOWFORD ROAD | ||||||||
| Address2: | 20B | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704576303 | ||||||||
| FaxNumber: | 7704572823 | ||||||||
| Practice Location | |||||||||
| Address1: | 4553 N SHALLOWFORD ROAD | ||||||||
| Address2: | 20B | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704576303 | ||||||||
| FaxNumber: | 7704572823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAMES | ||||||||
| AuthorizedOfficialFirstName: | JEANETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7704576303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.