=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952909988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAIR BY LADY SHA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2020
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 E 3RD ST
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10553-5124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-340-4528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 WATERSTONE DR # 2
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-340-4528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAMEKA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-340-4528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------