Healthcare Provider Details

I. General information

NPI: 1043744295
Provider Name (Legal Business Name): LESLIE IVORY C.S.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5670 PEACHTREE DUNWOODY RD SUITE 820
ATLANTA GA
30342-1699
US

IV. Provider business mailing address

5670 PEACHTREE DUNWOODY RD SUITE 820
ATLANTA GA
30342-1699
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-1998
  • Fax: 404-531-4039
Mailing address:
  • Phone: 404-851-1998
  • Fax: 404-531-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number2652
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: