Healthcare Provider Details

I. General information

NPI: 1023630928
Provider Name (Legal Business Name): MICHELLES BEAUTY BAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3662 DRUID OAKS DR
VALDOSTA GA
31605-6542
US

IV. Provider business mailing address

1412 E PARK AVE STE D
VALDOSTA GA
31602-3224
US

V. Phone/Fax

Practice location:
  • Phone: 229-375-2547
  • Fax: 229-375-2547
Mailing address:
  • Phone: 229-375-2547
  • Fax: 229-375-2547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE HERRING
Title or Position: OWNER
Credential:
Phone: 229-375-2547