=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477431377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QSM ENTERPRISE CO.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 09/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4046 JIMMIE DYESS PKWY
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-9468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-840-0634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4323 MEMORY LN
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-1115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-229-6770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASTERS COSMETOLOGIST
-----------------------------------------------------
Name | QUENYA MCMILLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-229-6770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------