Provider Demographics
NPI:1013552371
Name:MIAZ HAIR GALLERY
Entity Type:Organization
Organization Name:MIAZ HAIR GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-783-1878
Mailing Address - Street 1:PO BOX 906
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-0906
Mailing Address - Country:US
Mailing Address - Phone:770-783-1878
Mailing Address - Fax:
Practice Address - Street 1:1031 RAILROAD ST NW STE C
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5108
Practice Address - Country:US
Practice Address - Phone:770-783-1878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty