Healthcare Provider Details

I. General information

NPI: 1568582179
Provider Name (Legal Business Name): EASTSIDE ALLIED HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3081 STONE MOUNTAIN ST
LITHONIA GA
30058-4426
US

IV. Provider business mailing address

3081 STONE MOUNTAIN ST
LITHONIA GA
30058-4426
US

V. Phone/Fax

Practice location:
  • Phone: 770-482-1114
  • Fax: 770-484-1206
Mailing address:
  • Phone: 770-482-1114
  • Fax: 770-484-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR006698
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number021747
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number018820
License Number StateGA

VIII. Authorized Official

Name: DR. KHAMIS WAJDI IBRAHIM
Title or Position: CLINIC DIRECTOR
Credential: D.C.
Phone: 770-482-1114