Healthcare Provider Details

I. General information

NPI: 1346581493
Provider Name (Legal Business Name): HAIR EXTENSION STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 TENCH RD STE 130
SUWANEE GA
30024-6738
US

IV. Provider business mailing address

4485 TENCH RD STE 130
SUWANEE GA
30024-6738
US

V. Phone/Fax

Practice location:
  • Phone: 404-723-9721
  • Fax:
Mailing address:
  • Phone: 404-723-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. VALGENICE LIDDELL
Title or Position: CEO
Credential:
Phone: 404-723-9721