MEDICARE: MRS. SHARON A GUILLORY WIG STYLIST 1/5/03

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	25149512	TX

General Provider Information

NPI Number	:	1770831463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHARON A GUILLORY WIG STYLIST 1/5/03

Provider Business Mailing Address
First Line	:	5441 S HULEN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132
Country	:	US
Telephone Number	:	817-346-4951
Fax Number	:

Provider Business Practice Location Address
First Line	:	5441 S HULEN STREET
Second Line	:	DONA'S WIGS
City	:	FORT WORTH
State	:	TX
Zip	:	76132
Country	:	US
Telephone Number	:	817-346-4951
Fax Number	:

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

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	08/28/2012

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