Healthcare Provider Details

I. General information

NPI: 1508784380
Provider Name (Legal Business Name): IMODEL BEAUTY BAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 NOAHS ARK RD STE 104
JONESBORO GA
30236-7455
US

IV. Provider business mailing address

4545 PARKWAY CIR
ATLANTA GA
30349-9403
US

V. Phone/Fax

Practice location:
  • Phone: 470-905-3193
  • Fax:
Mailing address:
  • Phone: 470-753-9303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: QUINISHA REID
Title or Position: OWNER
Credential:
Phone: 470-905-3193