Healthcare Provider Details

I. General information

NPI: 1881224228
Provider Name (Legal Business Name): TAILORED MADE HAIR REPLACEMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SWITZLER ST STE B
CENTRALIA MO
65240-1594
US

IV. Provider business mailing address

2521 LAORIS ST
COLUMBIA MO
65202-2224
US

V. Phone/Fax

Practice location:
  • Phone: 573-818-8554
  • Fax:
Mailing address:
  • Phone: 573-818-8554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: BRANDI ANN HARRIS
Title or Position: HAIR SPECIALIST
Credential:
Phone: 573-818-8554