Provider Demographics
NPI:1477233625
Name:MD TRICHOLOGY LLC
Entity Type:Organization
Organization Name:MD TRICHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRICHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:BCHHP
Authorized Official - Phone:219-595-0566
Mailing Address - Street 1:1630 45TH ST # B101
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3963
Mailing Address - Country:US
Mailing Address - Phone:219-595-0566
Mailing Address - Fax:
Practice Address - Street 1:1630 45TH ST # B101
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3963
Practice Address - Country:US
Practice Address - Phone:219-595-0566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty