Healthcare Provider Details

I. General information

NPI: 1518582568
Provider Name (Legal Business Name): XQUISITE HAAR LOSS RESTORATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 PASS RD STE C
GULFPORT MS
39501-6437
US

IV. Provider business mailing address

828 PASS RD STE C
GULFPORT MS
39501-6437
US

V. Phone/Fax

Practice location:
  • Phone: 228-547-4074
  • Fax:
Mailing address:
  • Phone: 228-547-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: DENISHA LOUISE WILLIAMS
Title or Position: OWNER
Credential: HAIR LOSS SPECIALIST
Phone: 228-547-4074