Healthcare Provider Details

I. General information

NPI: 1962913426
Provider Name (Legal Business Name): ELAINE MARY MITCHELL CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE MARY MITCHELL HAIR RESTORATION

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8818 LA MESA BLVD
LA MESA CA
91942-5407
US

IV. Provider business mailing address

4931 OCEAN VIEW BLVD
SAN DIEGO CA
92113
US

V. Phone/Fax

Practice location:
  • Phone: 619-302-2404
  • Fax: 619-262-6115
Mailing address:
  • Phone: 619-302-2404
  • 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:
Title or Position:
Credential:
Phone: