Healthcare Provider Details

I. General information

NPI: 1205235371
Provider Name (Legal Business Name): IDESTA RALPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
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

5530 OLD NATIONAL HWY BLDG 5530-B2
COLLEGE PARK GA
30349-6234
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number56083
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: