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General NPI Number Information
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NPI Number | 1730682725
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Entity Type | Organization
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Legal Business Name | DIVINE DERMATOLOGY & AESTHETICS LLC
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Dates
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Enumeration Date | 03/15/2018
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Last Update Date | 03/15/2018
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Provider Practice Location Address
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Address Line | 1039 GRANT ST SE STE A-11
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City | ATLANTA
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State | GA
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Zip | 30315-2014
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Country | US
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Telephone | 678-589-7546
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Fax | 678-589-7500
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Provider Business Mailing Address
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Address Line | 830 GLENWOOD AVE SE STE 510-209
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City | ATLANTA
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State | GA
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Zip | 30316-1966
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Country | US
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Telephone | 678-589-7546
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Fax | 678-589-7500
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | TUNISIA F. CORNELIUS
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Credential | MD
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Telephone | 678-589-7546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State | GA
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