MEDICARE: KOCHERA DOUGLAS HAIR LOSS SPECIALIST

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	1744P3200X	GA

General Provider Information

NPI Number	:	1154755502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOCHERA DOUGLAS HAIR LOSS SPECIALIST

Provider Business Mailing Address
First Line	:	3406 MILL STREAM LN SW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-6218
Country	:	US
Telephone Number	:	404-200-3316
Fax Number	:	770-405-8087

Provider Business Practice Location Address
First Line	:	2770 LENOX RD NE
Second Line	:	SUITE B7
City	:	ATLANTA
State	:	GA
Zip	:	30324-6006
Country	:	US
Telephone Number	:	404-816-6610
Fax Number	:

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

Provider Enumeration Date	:	08/21/2013
Last Update Date	:	08/21/2013

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