MEDICARE: MY REAL HAIR

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1295275741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY REAL HAIR

Provider Business Mailing Address
First Line	:	2232 PALMER TRL
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-1962
Country	:	US
Telephone Number	:	817-896-2489
Fax Number	:

Provider Business Practice Location Address
First Line	:	2232 PALMER TRL
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-1962
Country	:	US
Telephone Number	:	817-896-2489
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	GWEN HALLEY
Credential	:
Telephone Number	:	817-896-2489

Provider Enumeration Date	:	03/02/2017
Last Update Date	:	03/02/2017

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Directions to “MY REAL HAIR ” Practice Location

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