Healthcare Provider Details

I. General information

NPI: 1336673276
Provider Name (Legal Business Name): COSMO B HAIR SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 SHARTOM DR
AUGUSTA GA
30907-4716
US

IV. Provider business mailing address

805 SHARTOM DR
AUGUSTA GA
30907-4716
US

V. Phone/Fax

Practice location:
  • Phone: 706-829-3396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO111737
License Number StateGA

VIII. Authorized Official

Name: BRITTANY CRAFTON
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: CERTIFIED HAIR LOSS
Phone: 706-829-3396