MEDICARE: JUSTINE CLARISSA CARLISLE 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		AL

General Provider Information

NPI Number	:	1487143798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE CLARISSA CARLISLE CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	504 FORREST CIR NE
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35811-1938
Country	:	US
Telephone Number	:	256-261-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	3322 MEMORIAL PKWY SW STE 524
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-5367
Country	:	US
Telephone Number	:	256-261-4066
Fax Number	:

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

Provider Enumeration Date	:	05/02/2018
Last Update Date	:	05/02/2018

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