Healthcare Provider Details

I. General information

NPI: 1467074849
Provider Name (Legal Business Name): MARTHA TANESHA HINES CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 LOWER ROSWELL RD STE 106
MARIETTA GA
30068-4300
US

IV. Provider business mailing address

4880 LOWER ROSWELL RD STE 106
MARIETTA GA
30068-4300
US

V. Phone/Fax

Practice location:
  • Phone: 404-988-6645
  • Fax:
Mailing address:
  • Phone: 240-421-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number423537
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: