MEDICARE: ALICIA COLEY 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	1201111085	VA

General Provider Information

NPI Number	:	1134691223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA COLEY HAIR LOSS SPECIALIST

Provider Business Mailing Address
First Line	:	3712 JUNIPER LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8134
Country	:	US
Telephone Number	:	757-277-8268
Fax Number	:

Provider Business Practice Location Address
First Line	:	1531 AMBERLEY FOREST RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-4706
Country	:	US
Telephone Number	:	757-277-8268
Fax Number	:

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

Provider Enumeration Date	:	12/30/2018
Last Update Date	:	12/30/2018

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