Provider Demographics
NPI:1295101608
Name:CUSTOM HAIR EXTENSIONS & HAIR LOSS CENTER
Entity type:Organization
Organization Name:CUSTOM HAIR EXTENSIONS & HAIR LOSS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED HAIR LOSS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-754-3196
Mailing Address - Street 1:1900 GLENN CLUB DR
Mailing Address - Street 2:APT 1312
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3499
Mailing Address - Country:US
Mailing Address - Phone:678-754-3196
Mailing Address - Fax:
Practice Address - Street 1:3983 LAVISTA RD
Practice Address - Street 2:SUITE 164
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5153
Practice Address - Country:US
Practice Address - Phone:678-754-3196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty