Provider Demographics
NPI:1073217550
Name:DISCOVER YOUR ILLUSIONS HAIR RESTORATION CENTER
Entity Type:Organization
Organization Name:DISCOVER YOUR ILLUSIONS HAIR RESTORATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATASHIA
Authorized Official - Middle Name:ILICIA
Authorized Official - Last Name:WADE BELL
Authorized Official - Suffix:
Authorized Official - Credentials:CRANIAL SPECAILIST
Authorized Official - Phone:510-917-2624
Mailing Address - Street 1:2266 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-4717
Mailing Address - Country:US
Mailing Address - Phone:510-917-2624
Mailing Address - Fax:
Practice Address - Street 1:2266 47TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-4717
Practice Address - Country:US
Practice Address - Phone:510-917-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty