Healthcare Provider Details

I. General information

NPI: 1629496096
Provider Name (Legal Business Name): EDITH ABAKARE HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2558 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30311-1779
US

IV. Provider business mailing address

2558 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30311-1779
US

V. Phone/Fax

Practice location:
  • Phone: 404-505-0300
  • Fax: 404-792-7209
Mailing address:
  • Phone: 404-505-0300
  • Fax: 404-792-7209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO040882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: