Provider Demographics
NPI:1770272353
Name:EXTENSIONS OF U
Entity type:Organization
Organization Name:EXTENSIONS OF U
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR LOSS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BIBOMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-510-2604
Mailing Address - Street 1:625 CROSSHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0024
Mailing Address - Country:US
Mailing Address - Phone:404-510-2604
Mailing Address - Fax:
Practice Address - Street 1:3335 SPRING HILL PKWY SE # 22
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-690-8288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier