MEDICARE: GENESIS II HAIR REPLACEMENT STUDIO

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1992332837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS II HAIR REPLACEMENT STUDIO

Provider Business Mailing Address
First Line	:	405 E TAFT RD
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-3734
Country	:	US
Telephone Number	:	315-458-1074
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 E TAFT RD
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-3734
Country	:	US
Telephone Number	:	315-458-1074
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALICIA ANNE ELSNER
Credential	:
Telephone Number	:	315-727-6192

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	03/23/2020

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