MEDICARE: NINA ROSS HAIR THERAPY, LLC.

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	332B00000X	Durable Medical Equipment & Medical Supplies	1744P3200X	GA
2	261QH0100X	Health Service Clinic/Center	1744P3200X	GA

General Provider Information

NPI Number	:	1164884078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NINA ROSS HAIR THERAPY, LLC.

Provider Business Mailing Address
First Line	:	6111 PEACHTREE DUNWOODY RD STE E101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4513
Country	:	US
Telephone Number	:	678-561-4522
Fax Number	:

Provider Business Practice Location Address
First Line	:	6111 PEACHTREE DUNWOODY RD STE E101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4513
Country	:	US
Telephone Number	:	678-561-4522
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHANINA LASSITER
Credential	:	HAIR LOSS SPECIALIST
Telephone Number	:	678-561-4522

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/08/2018

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