Provider Demographics
NPI:1063925113
Name:HARDGRAVES, RYAN DAVID (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:HARDGRAVES
Suffix:
Gender:M
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 CHINQUAPIN LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-3913
Mailing Address - Country:US
Mailing Address - Phone:409-656-2262
Mailing Address - Fax:
Practice Address - Street 1:5015 CHINQUAPIN LN
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-3913
Practice Address - Country:US
Practice Address - Phone:409-656-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-12
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6488061744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty