Healthcare Provider Details

I. General information

NPI: 1447624374
Provider Name (Legal Business Name): BRIAN STEVEN JOLLEY HAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 CHEROKEE ST SUITE 9
MARIETTA GA
30060
US

IV. Provider business mailing address

1001 E. SUNSET ROAD UNIT 96595
LAS VEGAS NV
89193-1246
US

V. Phone/Fax

Practice location:
  • Phone: 770-590-8662
  • Fax:
Mailing address:
  • Phone: 702-798-0113
  • Fax: 866-291-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHADS000886
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: