MEDICARE: KRISTAL HALL HAIR LOSS SPECIALIST

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	174400000X	Specialist	229202	MD
2	332B00000X	Durable Medical Equipment & Medical Supplies	229202	MD
3	1744P3200X	Prosthetics Case Management	229292	MD

General Provider Information

NPI Number	:	1699024117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTAL HALL HAIR LOSS SPECIALIST

Provider Business Mailing Address
First Line	:	4410 STAMP RD
Second Line	:	SUITE 105
City	:	MARLOW HEIGHTS
State	:	MD
Zip	:	20748-6700
Country	:	US
Telephone Number	:	301-316-4526
Fax Number	:

Provider Business Practice Location Address
First Line	:	4410 STAMP RD STE 105
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-6700
Country	:	US
Telephone Number	:	301-316-4526
Fax Number	:

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

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	07/14/2020

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