Healthcare Provider Details

I. General information

NPI: 1952825838
Provider Name (Legal Business Name): MARY L HILL HAIR LOSS SPECIALIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 THORNTON DR.
FAYETTEVILLE GA
30214
US

IV. Provider business mailing address

185 THORNTON DR.
FAYETTEVILLE GA
30214
US

V. Phone/Fax

Practice location:
  • Phone: 770-329-0427
  • Fax:
Mailing address:
  • Phone: 770-329-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCOI001814
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: