Healthcare Provider Details

I. General information

NPI: 1437765724
Provider Name (Legal Business Name): SHANEA BUIE CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5977 WHITESVILLE RD STE 20
COLUMBUS GA
31904-3618
US

IV. Provider business mailing address

1639 BRADLEY PARK DR STE 500
COLUMBUS GA
31904-3623
US

V. Phone/Fax

Practice location:
  • Phone: 706-393-1915
  • Fax:
Mailing address:
  • Phone: 706-393-1915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: