Provider Demographics
NPI:1750855391
Name:CROWN AND GLORY HAIR REPLACEMENT LLC
Entity Type:Organization
Organization Name:CROWN AND GLORY HAIR REPLACEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED HAIR LOSS SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DESHONA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLOGIST
Authorized Official - Phone:314-467-0556
Mailing Address - Street 1:1474 STONEBURY CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6109
Mailing Address - Country:US
Mailing Address - Phone:314-467-0556
Mailing Address - Fax:
Practice Address - Street 1:1474 STONEBURY CT
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6109
Practice Address - Country:US
Practice Address - Phone:314-467-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty