MEDICARE: EDNA SHARIE MOCK CERT HAIR LOSS SPECI

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	CO116503	GA

General Provider Information

NPI Number	:	1124458476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDNA SHARIE MOCK CERT HAIR LOSS SPECI

Provider Business Mailing Address
First Line	:	2956 VINE GROVE ST
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-1782
Country	:	US
Telephone Number	:	770-990-3944
Fax Number	:	770-439-8870

Provider Business Practice Location Address
First Line	:	2956 VINE GROVE ST
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-1782
Country	:	US
Telephone Number	:	770-990-3944
Fax Number	:	770-439-8870

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2013
Last Update Date	:	11/24/2013

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