Provider Demographics
NPI:1275349508
Name:RESTORE WELLNESS AND MEDSPA LLC
Entity type:Organization
Organization Name:RESTORE WELLNESS AND MEDSPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-910-6220
Mailing Address - Street 1:665 GRADY PL SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2615
Mailing Address - Country:US
Mailing Address - Phone:404-910-6220
Mailing Address - Fax:404-595-2547
Practice Address - Street 1:112 ROGERS ST NE STE 1A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-1094
Practice Address - Country:US
Practice Address - Phone:404-890-5625
Practice Address - Fax:404-595-2547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty