Raytillia R. Balam, MASTER BARBER & COSM

Key facts

NPI

1477929933

Entity type

Individual (NPI type 1)

Primary specialty

Prosthetics Case Management 1744P3200X

License

CO126396 (GA)

Practice address

299 Water Crest Dr
Brunswick, GA 31523-6108

Phone

(912) 290-9898

NPI assigned

Aug 18, 2015

Sex

Female

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 6, 2016.

{
    "created_epoch": "1439856000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1454716800000",
    "number": "1477929933",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "299 WATER CREST DR",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315236108",
            "telephone_number": "912-290-9898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "299 WATER CREST DR",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315236108",
            "telephone_number": "912-290-9898"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BALAM",
        "first_name": "RAYTILLIA",
        "middle_name": "R.",
        "credential": "MASTER BARBER & COSM",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-08-18",
        "last_updated": "2016-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1744P3200X",
            "taxonomy_group": "",
            "desc": "Specialist, Prosthetics Case Management",
            "state": "GA",
            "license": "CO126396",
            "primary": true
        },
        {
            "code": "173C00000X",
            "taxonomy_group": "",
            "desc": "Reflexologist",
            "state": "GA",
            "license": "CO126396",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Brunswick, GA · Prosthetics Case Management in Georgia