MEDICARE: IDESTA MEDICAL INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207ZB0001X	Blood Banking & Transfusion Medicine Physician
2	261Q00000X	Clinic/Center
3	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1063185015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDESTA MEDICAL INC

Provider Business Mailing Address
First Line	:	4827 OLD NATIONAL HWY UNIT 2032
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30337-6234
Country	:	US
Telephone Number	:	239-895-7910
Fax Number	:	866-984-3729

Provider Business Practice Location Address
First Line	:	4827 OLD NATIONAL HWY UNIT 2032
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30337-6234
Country	:	US
Telephone Number	:	239-895-7910
Fax Number	:	866-984-3729

Authorized Official
Title or Position	:	OWNER
Name	:	IDESTA RALPH
Credential	:
Telephone Number	:	239-895-7910

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	11/12/2024

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Directions to “IDESTA MEDICAL INC ” Practice Location

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