Healthcare Provider Details

I. General information

NPI: 1689282865
Provider Name (Legal Business Name): MARQUETTA L THOMAS CRT HAIR REPLACEMENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 SOUTHERN AVE
FAYETTEVILLE NC
28306-2257
US

IV. Provider business mailing address

545 HILLIARD DR
FAYETTEVILLE NC
28311-2689
US

V. Phone/Fax

Practice location:
  • Phone: 910-978-3276
  • Fax:
Mailing address:
  • Phone: 910-978-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: