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General NPI Number Information
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NPI Number | 1417332503
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Entity Type | Organization
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Legal Business Name | CIVILIAN BARBER SURGEONS
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Dates
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Enumeration Date | 07/30/2015
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Last Update Date | 07/30/2015
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Provider Practice Location Address
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Address Line | 8079 TARA BLVD
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City | JONESBORO
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State | GA
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Zip | 30236-3294
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Country | US
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Telephone | 404-710-6136
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Fax |
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Provider Business Mailing Address
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Address Line | 8079 TARA BLVD
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City | JONESBORO
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State | GA
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Zip | 30236-3294
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Country | US
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Telephone | 404-710-6136
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Fax |
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Authorized Official
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Title or Position | MASTER BARBER
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Name | PROF. KARRIEM A DAVIS
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Credential | BARBER
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Telephone | 404-710-6136
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | BR018793
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License Number State | GA
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