Provider Demographics
NPI:1083385751
Name:ADVANCED HEALTHY HAIR
Entity Type:Organization
Organization Name:ADVANCED HEALTHY HAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-201-1518
Mailing Address - Street 1:8601 PISA DR APT 1425
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-2153
Mailing Address - Country:US
Mailing Address - Phone:407-201-1518
Mailing Address - Fax:
Practice Address - Street 1:2211 EDGEWATER DR STE 12
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5319
Practice Address - Country:US
Practice Address - Phone:407-490-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019005700Medicaid