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General NPI Number Information
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NPI Number | 1891141578
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Entity Type | Organization
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Legal Business Name | PEDIATRIC HAIR SOLUTIONS CORPORATION
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Dates
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Enumeration Date | 05/11/2016
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Last Update Date | 05/11/2016
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Provider Practice Location Address
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Address Line | 19460 OLD JETTON RD STE 201
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City | CORNELIUS
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State | NC
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Zip | 28031-6456
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Country | US
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Telephone | 704-909-9414
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Fax |
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Provider Business Mailing Address
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Address Line | 6923 SHANNON WILLOW RD STE 100
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City | CHARLOTTE
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State | NC
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Zip | 28226-1331
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Country | US
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Telephone | 704-909-9414
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Fax | 704-496-9512
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JOHN E FASSLER
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Credential | 200200218
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Telephone | 803-517-5869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 200200218
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License Number State | NC
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