Healthcare Provider Details

I. General information

NPI: 1164016978
Provider Name (Legal Business Name): KHRISHUNDA UPSHAW TRICHOLOGIST/HHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 TEMPLE AVE STE D
LONG BEACH CA
90806-2280
US

IV. Provider business mailing address

2916 GARONA DR
HACIENDA HEIGHTS CA
91745-6647
US

V. Phone/Fax

Practice location:
  • Phone: 310-754-5297
  • Fax:
Mailing address:
  • Phone: 310-754-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number228944003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number228944003
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number228944003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: