Provider Demographics
NPI:1043975188
Name:TAI DAVIS MEDICAL WIGS
Entity type:Organization
Organization Name:TAI DAVIS MEDICAL WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TNESHEIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-482-5503
Mailing Address - Street 1:2451 CUMBERLAND PKWY SE STE 447
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6136
Mailing Address - Country:US
Mailing Address - Phone:404-482-5503
Mailing Address - Fax:
Practice Address - Street 1:2451 CUMBERLAND PKWY SE STE 447
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-6136
Practice Address - Country:US
Practice Address - Phone:404-482-5503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier