=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952992687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAGENNEH STYLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2021
-----------------------------------------------------
Last Update Date | 01/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9705 NORTHEAST PKWY STE 113
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28105-9703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-430-5897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7411 OLD WELL STREET APT I
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA HENNEGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-430-5897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------