Healthcare Provider Details

I. General information

NPI: 1497468714
Provider Name (Legal Business Name): PORSCHE' QUINCOLA THOMAS MEDICAL WIG PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: POR'SHAY QUINCOLA THOMAS POR'SHAY THOMAS

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 PEACHTREE RD NE STE 527
ATLANTA GA
30326-3287
US

IV. Provider business mailing address

3535 PEACHTREE RD NE P.O.BOX 527
ATLANTA GA
30326
US

V. Phone/Fax

Practice location:
  • Phone: 734-686-7523
  • Fax: 404-671-8588
Mailing address:
  • Phone: 734-686-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: