=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528645819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAIR DECOR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7205 ALMEDA RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-2191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-653-3319
-----------------------------------------------------
Fax | 832-583-1020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 300617
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77230-0617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-653-3319
-----------------------------------------------------
Fax | 832-583-1020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LATESHA R SMITH
-----------------------------------------------------
Credential | CRANIAL PROSTH SPEC
-----------------------------------------------------
Telephone | 713-653-3319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------