=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053895177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASHA'S HAIR STUDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2018
-----------------------------------------------------
Last Update Date | 09/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 SHARTOM DR
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-461-1118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 MURRAH ROAD EXT APT C203
-----------------------------------------------------
City | NORTH AUGUSTA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29860-9349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-461-1118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HAIR LOSS SPECIALIST
-----------------------------------------------------
Name | DELASHA TAKETHA WALTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-461-1118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------