=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801948369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUINTESSA MEDICAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 CLEVELAND AVE SW STE 602
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30315-7116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-767-8884
-----------------------------------------------------
Fax | 404-767-8815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4896 TREE TOPS DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-2667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-767-8884
-----------------------------------------------------
Fax | 404-767-8815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | SHAKOORA OMONUWA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-767-8884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 037895
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------