Provider Demographics
NPI:1467150110
Name:REVIVING CROWNS SOLUTIONS LLC
Entity Type:Organization
Organization Name:REVIVING CROWNS SOLUTIONS LLC
Other - Org Name:REVIVING CROWNS SOLUTIONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARQUISHA
Authorized Official - Middle Name:SHANKEIA
Authorized Official - Last Name:GENERAL
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:770-580-2380
Mailing Address - Street 1:3379 PEACHTREE RD NE STE 655-S24
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1031
Mailing Address - Country:US
Mailing Address - Phone:770-580-2380
Mailing Address - Fax:770-628-5144
Practice Address - Street 1:1812 N BROWN RD STE 30-113
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-1801
Practice Address - Country:US
Practice Address - Phone:770-580-2380
Practice Address - Fax:770-628-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier