MEDICARE: BALD ELECTROLYSIS

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1154193589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALD ELECTROLYSIS

Provider Business Mailing Address
First Line	:	2544 15TH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-3902
Country	:	US
Telephone Number	:	512-944-3756
Fax Number	:

Provider Business Practice Location Address
First Line	:	2544 15TH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-3902
Country	:	US
Telephone Number	:	512-944-3756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FALAN MOUTON
Credential	:	MD
Telephone Number	:	512-944-3756

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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