MEDICARE: MARTHA TANESHA HINES CERTIFIED HAIR LOSS

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	423537	MD

General Provider Information

NPI Number	:	1467074849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA TANESHA HINES CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	8777 CONTEE RD APT 304
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20708-1936
Country	:	US
Telephone Number	:	240-421-2872
Fax Number	:

Provider Business Practice Location Address
First Line	:	3407 FORT MEADE RD STE 14
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20724-2003
Country	:	US
Telephone Number	:	240-898-6523
Fax Number	:

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

Provider Enumeration Date	:	05/08/2020
Last Update Date	:	05/08/2020

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