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General NPI Number Information
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NPI Number | 1437394764
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Entity Type | Organization
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Legal Business Name | COASTAL HAIR RESTORATION, INC
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Dates
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Enumeration Date | 12/16/2008
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Last Update Date | 12/16/2008
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Provider Practice Location Address
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Address Line | 3082 BRICKHOUSE CT
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-6859
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Country | US
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Telephone | 757-486-0067
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Fax | 757-486-0061
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Provider Business Mailing Address
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Address Line | 3082 BRICKHOUSE CT
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-6859
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Country | US
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Telephone | 757-486-0067
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Fax | 757-486-0061
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLENN BARRON CHESHIRE
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Credential | M.D.
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Telephone | 757-486-0067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 0101229833
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License Number State | VA
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