=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992436547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBRACE AU NATURAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 S MAIN ST STE 103
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-4966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-336-9993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 RED OAK LN
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-336-9993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER MIGNOTT-STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-336-9993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------