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General NPI Number Information
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NPI Number | 1043716392
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Entity Type | Organization
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Legal Business Name | BROOKHAVEN AESTHESTIC INSTITUTE
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Dates
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Enumeration Date | 04/04/2018
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Last Update Date | 02/01/2019
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Provider Practice Location Address
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Address Line | 1418 DRESDEN DR NE STE 120
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City | BROOKHAVEN
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State | GA
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Zip | 30319
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Country | US
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Telephone | 404-481-5089
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Fax | 404-795-0461
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Provider Business Mailing Address
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Address Line | 3535 PEACHTREE RD NE STE 520-631
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City | ATLANTA
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State | GA
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Zip | 30326-3287
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Country | US
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Telephone | 404-481-5089
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Fax | 404-795-0461
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Authorized Official
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Title or Position | CEO
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Name | DR. PULI PRAVIN REDDY
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Credential | MD
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Telephone | 404-754-1994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 46220
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License Number State | GA
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