Provider Demographics
NPI:1780312884
Name:CROWNED GODDESS LUXURY VIRGIN HAIR
Entity type:Organization
Organization Name:CROWNED GODDESS LUXURY VIRGIN HAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:JEWEL
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-699-0028
Mailing Address - Street 1:3565 MARTIN LUTHER KING DR SW STE 9
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-4016
Mailing Address - Country:US
Mailing Address - Phone:404-699-0025
Mailing Address - Fax:
Practice Address - Street 1:3565 MARTIN LUTHER KING DR SW STE 9
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-4016
Practice Address - Country:US
Practice Address - Phone:404-699-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier