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General NPI Number Information
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NPI Number | 1164375549
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Entity Type | Organization
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Legal Business Name | MISHARI PRIMARY CARE AND AESTHETICS LLC
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Dates
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Enumeration Date | 02/17/2026
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Last Update Date | 02/17/2026
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Provider Practice Location Address
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Address Line | 2704 HAYNESCREST DR
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City | GRAYSON
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State | GA
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Zip | 30017-4280
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Country | US
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Telephone | 678-834-3828
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Fax |
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Provider Business Mailing Address
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Address Line | 2704 HAYNESCREST DR
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City | GRAYSON
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State | GA
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Zip | 30017-4280
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Country | US
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Telephone | 678-834-3828
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANASTACIA P MODO
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Credential | FNP-C
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Telephone | 678-834-3828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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