Healthcare Provider Details

I. General information

NPI: 1598225534
Provider Name (Legal Business Name): TAKARA N HARRIS TRICHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3766 US HIGHWAY 17 STE 102
RICHMOND HILL GA
31324-8872
US

IV. Provider business mailing address

172 SAINT IVES DR
SAVANNAH GA
31419-8917
US

V. Phone/Fax

Practice location:
  • Phone: 921-312-7272
  • Fax:
Mailing address:
  • Phone: 912-312-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCO124945
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: