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General NPI Number Information
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NPI Number | 1063981678
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Entity Type | Organization
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Legal Business Name | KENNESAW LUXARY HAIR BOUTIQUE
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Dates
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Enumeration Date | 11/13/2018
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Last Update Date | 11/13/2018
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Provider Practice Location Address
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Address Line | 3555 SANDERLINGS POINTE NW
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City | KENNESAW
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State | GA
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Zip | 30152-5822
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Country | US
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Telephone | 678-873-5853
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Fax |
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Provider Business Mailing Address
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Address Line | 3555 SANDERLINGS POINTE NW
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City | KENNESAW
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State | GA
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Zip | 30152-5822
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN COOK GRIFFIN
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Credential |
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Telephone | 770-427-7887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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