MEDICARE: FANTASY HAIR & BRAIDS

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

General Provider Information

NPI Number	:	1235839424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FANTASY HAIR & BRAIDS

Provider Business Mailing Address
First Line	:	705 CHICKASAW TRCE
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-2916
Country	:	US
Telephone Number	:	214-853-1950
Fax Number	:

Provider Business Practice Location Address
First Line	:	5208 AIRPORT FWY STE 170
Second Line	:
City	:	HALTOM CITY
State	:	TX
Zip	:	76117-5922
Country	:	US
Telephone Number	:	214-853-1950
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JESULA LONGCHAMP
Credential	:	CO,CPS
Telephone Number	:	214-853-1950

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/06/2023

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