Healthcare Provider Details

I. General information

NPI: 1801532957
Provider Name (Legal Business Name): XTEND MY HAIR SALON & CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 DYER ST
MALVERN AR
72104-5255
US

IV. Provider business mailing address

1004 DYER ST
MALVERN AR
72104-5255
US

V. Phone/Fax

Practice location:
  • Phone: 501-229-1008
  • Fax:
Mailing address:
  • Phone: 501-229-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: TERRENCE RANDELL MITCHELL
Title or Position: OWNER/OPERATOR
Credential:
Phone: 501-732-6041