MEDICARE: PHYLLIS L ALLEN HAIR RESTORATION SPE

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	1744P3200X	Prosthetics Case Management	CL0227470	FL

General Provider Information

NPI Number	:	1417478447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS L ALLEN HAIR RESTORATION SPE

Provider Business Mailing Address
First Line	:	5759 EDGEWATER DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32810-5258
Country	:	US
Telephone Number	:	407-733-0705
Fax Number	:	407-521-1595

Provider Business Practice Location Address
First Line	:	5759 EDGEWATER DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32810-5258
Country	:	US
Telephone Number	:	407-733-0705
Fax Number	:	407-521-1595

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

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	07/21/2022

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