Healthcare Provider Details

I. General information

NPI: 1669920575
Provider Name (Legal Business Name): DERINA HORTON-GARCIA CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DERINA GARCIA CERTIFIED HAIR LOSS

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 E STAN SCHLUETER LOOP STE 201
KILLEEN TX
76542-4516
US

IV. Provider business mailing address

5214 SILTSTONE LOOP
KILLEEN TX
76542-5815
US

V. Phone/Fax

Practice location:
  • Phone: 254-220-9921
  • Fax:
Mailing address:
  • Phone: 254-220-9921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1178165
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: