=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700142981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE LOOK SALON AND HAIR LOSS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2012
-----------------------------------------------------
Last Update Date | 04/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 AYERS AVE NE
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-420-9091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 801445
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-420-9091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HAIR LOSS SPECIALIST/OWNER
-----------------------------------------------------
Name | MRS. RYKETIA STRONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-420-9091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | CO090389
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------