Healthcare Provider Details

I. General information

NPI: 1841153194
Provider Name (Legal Business Name): TEA HOUSE ESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 NORTHSIDE DRIVE NE M210
ATLANTA GA
30324
US

IV. Provider business mailing address

1042 NORTHSIDE DRIVE NE M210
ATLANTA GA
30324
US

V. Phone/Fax

Practice location:
  • Phone: 470-538-7129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TORI SIMS
Title or Position: DIRECTOR
Credential:
Phone: 470-538-7129