MEDICARE: 29TH & GLAM EXTENSIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	332BC3200X	Customized Equipment (DME)
3	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1073275780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	29TH & GLAM EXTENSIONS LLC

Provider Business Mailing Address
First Line	:	1250 POWDER SPRINGS ST APT 2021
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-5249
Country	:	US
Telephone Number	:	706-668-7657
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 POWDER SPRINGS ST APT 2021
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-5249
Country	:	US
Telephone Number	:	706-668-7657
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHEVON M PHILLIPS
Credential	:
Telephone Number	:	706-668-7657

Provider Enumeration Date	:	10/11/2021
Last Update Date	:	10/11/2021

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