Healthcare Provider Details

I. General information

NPI: 1295328961
Provider Name (Legal Business Name): CRIMSON BEAUTY SALON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2021
Last Update Date: 02/14/2021
Certification Date: 02/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MORELAND AVE NE STE 18
ATLANTA GA
30307-2659
US

IV. Provider business mailing address

2295 SHADY DR
MORROW GA
30260-3131
US

V. Phone/Fax

Practice location:
  • Phone: 678-481-3896
  • Fax:
Mailing address:
  • Phone: 678-481-3896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: TRACI YVONNE BURTON
Title or Position: OWNER
Credential: HLP
Phone: 678-481-3896