Healthcare Provider Details

I. General information

NPI: 1407319676
Provider Name (Legal Business Name): TAVORIES IVEY SR. HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4409 SILVERTON RD
AUGUSTA GA
30909-9122
US

IV. Provider business mailing address

4409 SILVERTON RD
AUGUSTA GA
30909-9122
US

V. Phone/Fax

Practice location:
  • Phone: 706-466-2251
  • Fax:
Mailing address:
  • Phone: 706-466-2251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBR020119
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: