=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356746002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY LITTLE SECRET HAIR CONSULTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2014
-----------------------------------------------------
Last Update Date | 10/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1109 E ARCHWOOD AVE
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-475-9905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 E ARCHWOOD AVE
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-475-9905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA MORGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-475-9905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------