Healthcare Provider Details

I. General information

NPI: 1093322687
Provider Name (Legal Business Name): XTEND MY HAIR SALON & CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 DYER ST
MALVERN AR
72104-5255
US

IV. Provider business mailing address

327 WOODLAND ST
MALVERN AR
72104-3334
US

V. Phone/Fax

Practice location:
  • Phone: 501-732-6041
  • Fax:
Mailing address:
  • Phone: 150-173-2604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRENCE RANDELL MITCHELL
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: HAIR LOSS SPECIALIST
Phone: 501-732-6041