Healthcare Provider Details

I. General information

NPI: 1427587088
Provider Name (Legal Business Name): DEQUARUS TERRELL NEVETT CRANIAL PROSTHESIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 FAIRFAX DR APT 32
FAIRFIELD AL
35064-1063
US

IV. Provider business mailing address

407-32 FAIRFAX DRIVE
FAIRFIELD AL
35064
US

V. Phone/Fax

Practice location:
  • Phone: 205-520-6922
  • Fax:
Mailing address:
  • Phone: 205-520-6922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744G0900X
TaxonomyGraphics Designer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number125172
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: