Healthcare Provider Details

I. General information

NPI: 1952791147
Provider Name (Legal Business Name): TAILOR MADE LOOKS INSTITUTE OF PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3193 HOWELL MILL RD NW SUITE 328
ATLANTA GA
30327-2119
US

IV. Provider business mailing address

3193 HOWELL MILL RD NW SUITE 328
ATLANTA GA
30327-2119
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-9355
  • Fax: 404-350-9069
Mailing address:
  • Phone: 404-350-9355
  • Fax: 404-350-9069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number20800000X
License Number StateGA

VIII. Authorized Official

Name: DR. MEDHANIE CHICHI BERHANE
Title or Position: SURGEON
Credential: M.D.
Phone: 404-350-9355