Healthcare Provider Details

I. General information

NPI: 1356014146
Provider Name (Legal Business Name): HER CRANIAL PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6803 OLD ALEXANDRIA FERRY RD
CLINTON MD
20735-1744
US

IV. Provider business mailing address

7810 DELANO RD
CLINTON MD
20735-1829
US

V. Phone/Fax

Practice location:
  • Phone: 202-743-4602
  • Fax: 202-217-2644
Mailing address:
  • Phone: 202-400-9129
  • Fax: 202-217-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAKEITA BOYD
Title or Position: OWNER
Credential:
Phone: 202-743-4602