Healthcare Provider Details

I. General information

NPI: 1417332503
Provider Name (Legal Business Name): CIVILIAN BARBER SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8079 TARA BLVD
JONESBORO GA
30236-3294
US

IV. Provider business mailing address

8079 TARA BLVD
JONESBORO GA
30236-3294
US

V. Phone/Fax

Practice location:
  • Phone: 404-710-6136
  • Fax:
Mailing address:
  • Phone: 404-710-6136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberBR018793
License Number StateGA

VIII. Authorized Official

Name: PROF. KARRIEM A DAVIS
Title or Position: MASTER BARBER
Credential: BARBER
Phone: 404-710-6136