Healthcare Provider Details

I. General information

NPI: 1194043380
Provider Name (Legal Business Name): SEXY-N-LACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 ETOWAH DR SE
ACWORTH GA
30102-3108
US

IV. Provider business mailing address

4230 ETOWAH DRIVE SE
ACWORTH GA
30102-3108
US

V. Phone/Fax

Practice location:
  • Phone: 678-516-2157
  • Fax: 866-249-3717
Mailing address:
  • Phone: 678-516-2157
  • Fax: 866-249-3717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. BRIDGET REYNOLDS REYNOLDS
Title or Position: OWNER
Credential:
Phone: 678-516-2157