Healthcare Provider Details

I. General information

NPI: 1730822057
Provider Name (Legal Business Name): SMILEY'S HAIR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 1ST AVE STE E
TUCKER GA
30084-4469
US

IV. Provider business mailing address

4229 1ST AVE STE E
TUCKER GA
30084-4469
US

V. Phone/Fax

Practice location:
  • Phone: 678-515-7523
  • Fax:
Mailing address:
  • Phone: 678-515-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State

VIII. Authorized Official

Name: SHARMELE WEST SMITH
Title or Position: CERTIFIED MASTECTOMY FITTER
Credential: CMF
Phone: 678-515-7523