Healthcare Provider Details

I. General information

NPI: 1447594569
Provider Name (Legal Business Name): HARLEY ANTI-AGING INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2678 BUFORD HIGHWAY NE
ATLANTA GA
30324
US

IV. Provider business mailing address

2678 BUFORD HWY NE
ATLANTA GA
30324-3240
US

V. Phone/Fax

Practice location:
  • Phone: 678-500-1066
  • Fax:
Mailing address:
  • Phone: 678-500-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number28500
License Number StateGA

VIII. Authorized Official

Name: DR. SHARON A HARLEY
Title or Position: MEDICAL DOCTOR
Credential:
Phone: 678-500-1066