Healthcare Provider Details

I. General information

NPI: 1801492210
Provider Name (Legal Business Name): GIFTED CREATION RESTORATION HAIR LOSS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BUTLER ST STE D-5
MIDWAY GA
31320-4575
US

IV. Provider business mailing address

PO BOX 641
MIDWAY GA
31320-0641
US

V. Phone/Fax

Practice location:
  • Phone: 912-463-2883
  • Fax: 912-385-9240
Mailing address:
  • Phone: 912-463-2883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHONDA KING
Title or Position: TRICHOLOGISTS
Credential: AMCA
Phone: 912-463-2883