Healthcare Provider Details

I. General information

NPI: 1548672017
Provider Name (Legal Business Name): HAIR IMAGE AND EXPRESSIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 SAINT ANDREW ST
TARBORO NC
27886-2534
US

IV. Provider business mailing address

1516 SAINT ANDREW ST
TARBORO NC
27886-2534
US

V. Phone/Fax

Practice location:
  • Phone: 252-885-7695
  • Fax:
Mailing address:
  • Phone: 252-885-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberC68563
License Number StateNC

VIII. Authorized Official

Name: MS. LORETTA RANA HILLIARD
Title or Position: COSMETOLOGIST/ HAIR REPLACEMET SPEC
Credential: COS/ ESTHECTICIAN
Phone: 252-885-7695