Healthcare Provider Details

I. General information

NPI: 1518599968
Provider Name (Legal Business Name): KENYATTA BUTCHER HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S STONY ISLAND AVE
CHICAGO IL
60617-1734
US

IV. Provider business mailing address

5225 N KENMORE AVE
CHICAGO IL
60640-2445
US

V. Phone/Fax

Practice location:
  • Phone: 312-623-9966
  • Fax:
Mailing address:
  • Phone: 773-931-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: