1619491529 NPI number — BRIAN DEMETRIUS HAM HAIR LOSS SPECIALIST

Table of content: BRIAN DEMETRIUS HAM HAIR LOSS SPECIALIST (NPI 1619491529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619491529 NPI number — BRIAN DEMETRIUS HAM HAIR LOSS SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAM
Provider First Name:
BRIAN
Provider Middle Name:
DEMETRIUS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HAIR LOSS SPECIALIST
Provider Gender Code:
M

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:
1619491529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 W CAROLINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29550-4216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-309-9754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 W CAROLINA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29550-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-309-9754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2017

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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