=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356169197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUTIFUL LIFE CHANGES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11720 AMBER PARK DR STE 160
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-2271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-408-9944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11720 AMBER PARK DR STE 160
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-2271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-404-4089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LAMONICA TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-450-6778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------