MEDICARE: PEDIATRIC HAIR SOLUTIONS

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	261QH0100X	Health Service Clinic/Center	200200218	NC

General Provider Information

NPI Number	:	1235583626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC HAIR SOLUTIONS

Provider Business Mailing Address
First Line	:	6923 SHANNON WILLOW RD
Second Line	:	STE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-1330
Country	:	US
Telephone Number	:	704-909-9414
Fax Number	:

Provider Business Practice Location Address
First Line	:	951 WORTHINGTON WOODS LOOP RD
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-5743
Country	:	US
Telephone Number	:	704-909-9414
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	JOHN E FASSLER
Credential	:	M.D.
Telephone Number	:	704-909-9414

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	04/21/2016

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