Provider Demographics
NPI:1871398842
Name:GATEWOOD CLINIC AND MEDSPA
Entity type:Organization
Organization Name:GATEWOOD CLINIC AND MEDSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-685-0718
Mailing Address - Street 1:2989 WILSONE PL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3379
Mailing Address - Country:US
Mailing Address - Phone:770-685-0718
Mailing Address - Fax:678-615-2314
Practice Address - Street 1:715 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3379
Practice Address - Country:US
Practice Address - Phone:470-823-3051
Practice Address - Fax:678-615-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty