1477914554 NPI number — TAKESHA L SALES CERT HAIR LOSS SPECI

Table of content: TAKESHA L SALES CERT HAIR LOSS SPECI (NPI 1477914554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477914554 NPI number — TAKESHA L SALES CERT HAIR LOSS SPECI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALES
Provider First Name:
TAKESHA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERT HAIR LOSS SPECI
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477914554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1607 LAURENS RD
Provider Second Line Business Mailing Address:
SUITE #109
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-2961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-283-6804
Provider Business Mailing Address Fax Number:
864-283-6805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1607 LAURENS RD
Provider Second Line Business Practice Location Address:
SUITE #109
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-283-6804
Provider Business Practice Location Address Fax Number:
864-283-6805
Provider Enumeration Date:
03/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1744P3200X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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