Provider Demographics
NPI:1982215778
Name:CALVIN, BONTAYA (CERTIFIED HAIRLOSS)
Entity Type:Individual
Prefix:
First Name:BONTAYA
Middle Name:
Last Name:CALVIN
Suffix:
Gender:F
Credentials:CERTIFIED HAIRLOSS
Other - Prefix:
Other - First Name:BONTAYA
Other - Middle Name:
Other - Last Name:CALVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4305 HARVEST HILL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38141-6933
Mailing Address - Country:US
Mailing Address - Phone:901-652-2908
Mailing Address - Fax:
Practice Address - Street 1:4305 HARVEST HILL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38141-6933
Practice Address - Country:US
Practice Address - Phone:901-236-9256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN157804224P00000X, 1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty