=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508655697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 6IXTH AVENUE BEAUTY BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 BOHLER AVE
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-627-8209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 HOLIDAY DR
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-1436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-524-5016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | ARLRAN J EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-627-8209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------