Healthcare Provider Details

I. General information

NPI: 1154755502
Provider Name (Legal Business Name): KOCHERA DOUGLAS HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 LENOX RD NE SUITE B7
ATLANTA GA
30324-6006
US

IV. Provider business mailing address

3406 MILL STREAM LN SW
MARIETTA GA
30060-6218
US

V. Phone/Fax

Practice location:
  • Phone: 404-816-6610
  • Fax:
Mailing address:
  • Phone: 404-200-3316
  • Fax: 770-405-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1744P3200X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: