Healthcare Provider Details

I. General information

NPI: 1447604178
Provider Name (Legal Business Name): ERA RUSSELL HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 11/01/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 W POINT RD SUITE 36
LAGRANGE GA
30240-4007
US

IV. Provider business mailing address

2170 W POINT RD SUITE 36
LAGRANGE GA
30240-4007
US

V. Phone/Fax

Practice location:
  • Phone: 762-323-7874
  • Fax:
Mailing address:
  • Phone: 762-323-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number224P00000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: