Provider Demographics
NPI:1588283113
Name:FOR YOUR GLORY CRANIAL PROSTHETICS
Entity type:Organization
Organization Name:FOR YOUR GLORY CRANIAL PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-338-5731
Mailing Address - Street 1:501 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2721
Mailing Address - Country:US
Mailing Address - Phone:678-338-5731
Mailing Address - Fax:678-338-5731
Practice Address - Street 1:501 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2721
Practice Address - Country:US
Practice Address - Phone:678-338-5731
Practice Address - Fax:678-338-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier