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General NPI Number Information
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NPI Number | 1770272353
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Entity Type | Organization
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Legal Business Name | EXTENSIONS OF U
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Dates
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Enumeration Date | 05/01/2023
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Last Update Date | 05/01/2023
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Provider Practice Location Address
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Address Line | 3335 SPRING HILL PKWY SE # 22
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City | SMYRNA
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State | GA
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Zip | 30080
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Country | US
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Telephone | 770-690-8288
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Fax |
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Provider Business Mailing Address
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Address Line | 625 CROSSHAVEN DR
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City | MARIETTA
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State | GA
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Zip | 30066-0024
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Country | US
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Telephone | 404-510-2604
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Fax |
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Authorized Official
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Title or Position | HAIR LOSS SPECIALIST
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Name | BIBOMBA DAVENPORT
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Credential |
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Telephone | 404-510-2604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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