Provider Demographics
NPI:1770038937
Name:HAIR REPLACEMENT CLINIC
Entity Type:Organization
Organization Name:HAIR REPLACEMENT CLINIC
Other - Org Name:DERITA STRONG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPECIALIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERITA
Authorized Official - Middle Name:JOH'NAY
Authorized Official - Last Name:STRONG
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR REPLACEMENT
Authorized Official - Phone:316-390-1280
Mailing Address - Street 1:1815 S WINDSOR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218
Mailing Address - Country:US
Mailing Address - Phone:316-390-1280
Mailing Address - Fax:
Practice Address - Street 1:1815 S WINDSOR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218
Practice Address - Country:US
Practice Address - Phone:316-390-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAIR REPLACEMENT CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS296471744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS9860Medicaid