Healthcare Provider Details

I. General information

NPI: 1134874241
Provider Name (Legal Business Name): DE'BORAH VIRTUOUS HANDS HAIR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11909 E DR MARTIN LUTHER KING JR BLVD
SEFFNER FL
33584-4934
US

IV. Provider business mailing address

10390 SCARLETT SKIMMER DR
RIVERVIEW FL
33578-6277
US

V. Phone/Fax

Practice location:
  • Phone: 919-914-4197
  • Fax:
Mailing address:
  • Phone: 919-914-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DIANE M HOOKS
Title or Position: HAIR STYLIST
Credential:
Phone: 919-914-4197