Healthcare Provider Details

I. General information

NPI: 1699169268
Provider Name (Legal Business Name): MICHELL WHITBY HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 BACONSFIELD DR STE 109
MACON GA
31211-1491
US

IV. Provider business mailing address

750 BACONSFIELD DR STE 109
MACON GA
31211-1491
US

V. Phone/Fax

Practice location:
  • Phone: 478-447-0985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO092727
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: