Healthcare Provider Details

I. General information

NPI: 1851857189
Provider Name (Legal Business Name): FAIRYTALE HAIR L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S HIGHWAY 161
JACKSONVILLE AR
72076-5511
US

IV. Provider business mailing address

192 WILLIAMSBURG CV
CABOT AR
72023-9433
US

V. Phone/Fax

Practice location:
  • Phone: 501-605-3405
  • Fax:
Mailing address:
  • Phone: 501-650-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: BREANNA RICHARDSON
Title or Position: OWNER
Credential:
Phone: 501-650-3405