MEDICARE: COMPLETE LASER CLINIC OF ATLANTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician

General Provider Information

NPI Number	:	1053768309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPLETE LASER CLINIC OF ATLANTA

Provider Business Mailing Address
First Line	:	4751 BEST RD
Second Line	:	SUITE 400Q
City	:	ATLANTA
State	:	GA
Zip	:	30337-5615
Country	:	US
Telephone Number	:	678-515-4607
Fax Number	:	470-355-8524

Provider Business Practice Location Address
First Line	:	4751 BEST RD
Second Line	:	SUITE 400Q
City	:	ATLANTA
State	:	GA
Zip	:	30337-5615
Country	:	US
Telephone Number	:	678-515-4607
Fax Number	:	470-355-8524

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. ANISHUA M ROBERTS
Credential	:	CPC
Telephone Number	:	678-515-4607

Provider Enumeration Date	:	05/17/2016
Last Update Date	:	05/17/2016

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