Healthcare Provider Details

I. General information

NPI: 1245580174
Provider Name (Legal Business Name): SLENDER SPA MED ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 HOLCOMB BRIDGE RD SUITE 165
ROSWELL GA
30076-2139
US

IV. Provider business mailing address

1475 HOLCOMB BRIDGE RD SUITE 165
ROSWELL GA
30076-2139
US

V. Phone/Fax

Practice location:
  • Phone: 678-682-8600
  • Fax:
Mailing address:
  • Phone: 678-682-8600
  • Fax: 678-682-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANYA GRIZZLE
Title or Position: OWNER
Credential:
Phone: 678-682-8600