Provider Demographics
NPI:1528764784
Name:STAGE 1 HAIR LOSS REPLACEMENT & SALON
Entity type:Organization
Organization Name:STAGE 1 HAIR LOSS REPLACEMENT & SALON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALANDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-384-4532
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-0240
Mailing Address - Country:US
Mailing Address - Phone:601-384-4532
Mailing Address - Fax:601-384-4532
Practice Address - Street 1:216 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653
Practice Address - Country:US
Practice Address - Phone:601-384-4532
Practice Address - Fax:601-384-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-31
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1306214507Medicaid