Healthcare Provider Details

I. General information

NPI: 1558266510
Provider Name (Legal Business Name): BLACK ROYAL BEAUTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11961 VETERANS MEMORIAL HWY
DOUGLASVILLE GA
30134-4575
US

IV. Provider business mailing address

11961 VETERANS MEMORIAL HWY
DOUGLASVILLE GA
30134-4575
US

V. Phone/Fax

Practice location:
  • Phone: 404-910-9893
  • Fax:
Mailing address:
  • Phone: 404-910-9893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: DIENESIA PAYNES
Title or Position: OWNER
Credential:
Phone: 404-910-9893