Provider Demographics
NPI:1528587656
Name:EJUAN HAIR REPLACEMENT CENTER
Entity Type:Organization
Organization Name:EJUAN HAIR REPLACEMENT CENTER
Other - Org Name:EJUAN HAIR REPLACEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HAIR LOSS SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:EJUAN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:SMALLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:HLS
Authorized Official - Phone:404-834-0396
Mailing Address - Street 1:19 CENTENNIAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0256
Mailing Address - Country:US
Mailing Address - Phone:404-834-0396
Mailing Address - Fax:
Practice Address - Street 1:5043 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2733
Practice Address - Country:US
Practice Address - Phone:404-834-0396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-09
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO097738174400000X
GA1744P3200X, 332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment