=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962010645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAIR & SCALP RESTORATION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2020
-----------------------------------------------------
Last Update Date | 12/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 BRIARWOOD DR STE 102
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39206-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-590-6605
-----------------------------------------------------
Fax | 769-922-5992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 W MADISON ST
-----------------------------------------------------
City | YAZOO CITY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39194-3483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-590-6605
-----------------------------------------------------
Fax | 769-022-5992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEKO CARTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-590-6605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------