MEDICARE: MISS GUSLENE A BUBAK TRICHOLOGIST

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	335E00000X	Prosthetic/Orthotic Supplier	AEC1615663	NY

General Provider Information

NPI Number	:	1174335376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS GUSLENE A BUBAK TRICHOLOGIST

Provider Business Mailing Address
First Line	:	1734 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1734 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4127
Country	:	US
Telephone Number	:	646-620-3525
Fax Number	:

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

Provider Enumeration Date	:	01/23/2025
Last Update Date	:	01/31/2025

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