Healthcare Provider Details

I. General information

NPI: 1245850452
Provider Name (Legal Business Name): CHRISTINA ANTOINETTE BENJAMIN HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 HOLCOMB BRIDGE RD STE 205
ROSWELL GA
30076-4715
US

IV. Provider business mailing address

PO BOX 467271
ATLANTA GA
31146-7271
US

V. Phone/Fax

Practice location:
  • Phone: 248-986-8761
  • Fax:
Mailing address:
  • Phone: 248-986-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: