Healthcare Provider Details

I. General information

NPI: 1164192357
Provider Name (Legal Business Name): KEEPING U GORGEOUS EXTENSIONS &WIGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 MONTREAL RD
TUCKER GA
30084-5224
US

IV. Provider business mailing address

2015 MONTREAL RD
TUCKER GA
30084-5224
US

V. Phone/Fax

Practice location:
  • Phone: 404-861-8009
  • Fax:
Mailing address:
  • Phone: 404-861-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MS. KENISHA L GARRETT
Title or Position: OWNER
Credential: OWNER
Phone: 404-861-8009