=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932691474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUITE DIAMONDS N CURLS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2018
-----------------------------------------------------
Last Update Date | 05/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4826 WHITE OAK TRL
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30088-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-990-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 877
-----------------------------------------------------
City | PINE LAKE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30072-0877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-990-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YOLANDA LAST MURPHY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-990-4320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------