Healthcare Provider Details

I. General information

NPI: 1982215778
Provider Name (Legal Business Name): BONTAYA CALVIN CERTIFIED HAIRLOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BONTAYA CALVIN MD

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 HARVEST HILL RD
MEMPHIS TN
38141-6933
US

IV. Provider business mailing address

4305 HARVEST HILL RD
MEMPHIS TN
38141-6933
US

V. Phone/Fax

Practice location:
  • Phone: 901-236-9256
  • Fax:
Mailing address:
  • Phone: 901-652-2908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number157804
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number157804
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: