Provider Demographics
NPI:1447604178
Name:RUSSELL, ERA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:ERA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 W POINT RD
Mailing Address - Street 2:SUITE 36
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4007
Mailing Address - Country:US
Mailing Address - Phone:762-323-7874
Mailing Address - Fax:
Practice Address - Street 1:2170 W POINT RD
Practice Address - Street 2:SUITE 36
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4007
Practice Address - Country:US
Practice Address - Phone:762-323-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225000000X
GA224P00000X224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7708Medicaid