Healthcare Provider Details

I. General information

NPI: 1982143129
Provider Name (Legal Business Name): ANNTIONEEK BOSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 CRESTMARK DR SUITE 200
LITHIA SPRINGS GA
30122-2665
US

IV. Provider business mailing address

PO BOX 733
PALMETTO GA
30268-0733
US

V. Phone/Fax

Practice location:
  • Phone: 678-744-3440
  • Fax:
Mailing address:
  • Phone: 678-744-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateGA

VIII. Authorized Official

Name: MS. ANNTIONEEK MARSHELLE BOSTON
Title or Position: HAIR LOSS SPECIALIST
Credential: CERTIFIED
Phone: 678-744-3440