Provider Demographics
NPI:1114116050
Name:DR MANNYS HAIR RESTORATION CENTER
Entity Type:Organization
Organization Name:DR MANNYS HAIR RESTORATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-573-6111
Mailing Address - Street 1:1255 VISCAYA PKWY # 1
Mailing Address - Street 2:103
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3290
Mailing Address - Country:US
Mailing Address - Phone:239-573-6111
Mailing Address - Fax:239-573-9534
Practice Address - Street 1:1255 VISCAYA PKWY # 1
Practice Address - Street 2:103
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3290
Practice Address - Country:US
Practice Address - Phone:239-573-6111
Practice Address - Fax:239-573-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041260208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8556Medicare PIN
FLD63870Medicare UPIN