Healthcare Provider Details

I. General information

NPI: 1700232865
Provider Name (Legal Business Name): BELTLINE BARIATRIC AND SURGICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 11/01/2023
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 E PACES FERRY RD NE STE 750
ATLANTA GA
30305-2372
US

IV. Provider business mailing address

371 E PACES FERRY RD NE STE 750
ATLANTA GA
30305-2372
US

V. Phone/Fax

Practice location:
  • Phone: 470-419-4380
  • Fax: 470-298-7736
Mailing address:
  • Phone: 470-419-4380
  • Fax: 470-298-7736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANA KAPOU WONG
Title or Position: COO
Credential:
Phone: 770-686-1366