MEDICARE: SHUNDREA NEELY HAIR LOSS SPECIALIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1114582368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHUNDREA NEELY HAIR LOSS SPECIALIST

Provider Business Mailing Address
First Line	:	2 MONTCLAIR DR
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-1627
Country	:	US
Telephone Number	:	618-560-3068
Fax Number	:

Provider Business Practice Location Address
First Line	:	10301 LINCOLN TRL
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-1829
Country	:	US
Telephone Number	:	618-560-3068
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2019
Last Update Date	:	05/03/2019

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