Provider Demographics
NPI:1548349350
Name:HAIRSTON, STELLA UGO (CEO)
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:UGO
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4506 VAUGHAN DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-7503
Mailing Address - Country:US
Mailing Address - Phone:975-475-3358
Mailing Address - Fax:972-475-3385
Practice Address - Street 1:4506 VAUGHAN DR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-7503
Practice Address - Country:US
Practice Address - Phone:972-475-3358
Practice Address - Fax:972-475-3385
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX0084934332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5591130001Medicare NSC