MEDICARE: HAIR BAKERY BOUTIQUE LLC.

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	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1114505849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAIR BAKERY BOUTIQUE LLC.

Provider Business Mailing Address
First Line	:	225 FRANKLIN RD UNIT 3313
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30342-2752
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 FRANKLIN RD UNIT 3313
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30342-2752
Country	:	US
Telephone Number	:	843-224-8684
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVIDA MARIA ROACH
Credential	:
Telephone Number	:	843-224-8684

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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