Healthcare Provider Details

I. General information

NPI: 1881167344
Provider Name (Legal Business Name): ANNB HAIR COVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 LORA SMITH RD
NEWNAN GA
30265-1924
US

IV. Provider business mailing address

1128 LORA SMITH RD
NEWNAN GA
30265-1924
US

V. Phone/Fax

Practice location:
  • Phone: 678-744-3440
  • Fax:
Mailing address:
  • Phone: 678-972-4662
  • 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 Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. ANNTIONEEK BOSTON
Title or Position: HAIR LOSS SPECIALIST
Credential: BS,ED
Phone: 678-972-4662