Provider Demographics
NPI:1093322687
Name:XTEND MY HAIR SALON & CO LLC
Entity Type:Organization
Organization Name:XTEND MY HAIR SALON & CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED HAIR LOSS SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:RANDELL
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:501-732-6041
Mailing Address - Street 1:327 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-3334
Mailing Address - Country:US
Mailing Address - Phone:150-173-2604
Mailing Address - Fax:
Practice Address - Street 1:1004 DYER ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5255
Practice Address - Country:US
Practice Address - Phone:501-732-6041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier