Healthcare Provider Details

I. General information

NPI: 1164884078
Provider Name (Legal Business Name): NINA ROSS HAIR THERAPY, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 PEACHTREE DUNWOODY RD STE E101
ATLANTA GA
30328-4513
US

IV. Provider business mailing address

6111 PEACHTREE DUNWOODY RD STE E101
ATLANTA GA
30328-4513
US

V. Phone/Fax

Practice location:
  • Phone: 678-561-4522
  • Fax:
Mailing address:
  • Phone: 678-561-4522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1744P3200X
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1744P3200X
License Number StateGA

VIII. Authorized Official

Name: MRS. SHANINA LASSITER
Title or Position: OWNER
Credential: HAIR LOSS SPECIALIST
Phone: 678-561-4522