Healthcare Provider Details

I. General information

NPI: 1942859558
Provider Name (Legal Business Name): VENUS HAIR LOSS REPLACEMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S LINCOLN AVE
O FALLON IL
62269-2663
US

IV. Provider business mailing address

625 S LINCOLN AVE
O FALLON IL
62269-2663
US

V. Phone/Fax

Practice location:
  • Phone: 618-401-6359
  • Fax:
Mailing address:
  • Phone: 618-401-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: AKOSSIWA TATIANE AMENYO
Title or Position: HAIR LOSS SPECIALIST
Credential: CERTIFIED
Phone: 618-401-6359