Healthcare Provider Details

I. General information

NPI: 1245735067
Provider Name (Legal Business Name): XCLUSIVE KUTZ BARBERSHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 03/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 PARK AVE
MEMPHIS TN
38111-5630
US

IV. Provider business mailing address

3610 PARK AVE
MEMPHIS TN
38111-5630
US

V. Phone/Fax

Practice location:
  • Phone: 901-490-3749
  • Fax:
Mailing address:
  • Phone: 901-490-3749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DERICK TOLLIVER
Title or Position: OWNER
Credential: BARBER
Phone: 901-490-3749