Healthcare Provider Details

I. General information

NPI: 1407330012
Provider Name (Legal Business Name): JOILANDA RENEE THRASH HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 LAKE VALLEY RD
MACON GA
31210-3228
US

IV. Provider business mailing address

1170 LAKE VALLEY RD
MACON GA
31210-3228
US

V. Phone/Fax

Practice location:
  • Phone: 478-335-7053
  • Fax:
Mailing address:
  • Phone: 478-335-7053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO082666
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: