=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912299181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA LUXURY MEDICINE AND AESTHETICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2011
-----------------------------------------------------
Last Update Date | 05/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 PEACHTREE ST SUITE 3300
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303-1740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-946-1815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2880 MONTVIEW DR SW
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-5152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-664-7547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RICKEY WASHINGTON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-664-7547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 55463
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------