Healthcare Provider Details

I. General information

NPI: 1063185015
Provider Name (Legal Business Name): IDESTA MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 TYRONE RD # 410-C
TYRONE GA
30290-2407
US

IV. Provider business mailing address

4827 OLD NATIONAL HWY UNIT 2032
COLLEGE PARK GA
30337-6234
US

V. Phone/Fax

Practice location:
  • Phone: 470-818-2264
  • Fax: 866-984-3729
Mailing address:
  • Phone: 239-895-7910
  • Fax: 866-984-3729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: IDESTA RALPH
Title or Position: OWNER
Credential:
Phone: 239-895-7910