Provider Demographics
NPI:1629443387
Name:GRACE & BEAUTY HAIR RESTORATION AND TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:GRACE & BEAUTY HAIR RESTORATION AND TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JELEVA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-366-4429
Mailing Address - Street 1:5891 ASH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5891 ASH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-3016
Practice Address - Country:US
Practice Address - Phone:404-366-4429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0848471744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty