Healthcare Provider Details

I. General information

NPI: 1013629963
Provider Name (Legal Business Name): TRICHOLOGY HAIR LOSS PREVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 KNOLLWOOD ST
WINSTON SALEM NC
27103-3426
US

IV. Provider business mailing address

PO BOX 11762
WINSTON SALEM NC
27116-1762
US

V. Phone/Fax

Practice location:
  • Phone: 336-986-9063
  • Fax:
Mailing address:
  • Phone: 336-986-9063
  • Fax: 336-306-9713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: LEOLA MCMILLAN
Title or Position: PRACTITIONER
Credential: TRICHOLOGY HAIR LOSS
Phone: 336-918-8521