Healthcare Provider Details

I. General information

NPI: 1477238707
Provider Name (Legal Business Name): MAINY MANE HAIR BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 EAST MICHIGAN AVE
LANSING MI
48912
US

IV. Provider business mailing address

21370 INDEPENDENCE DR
SOUTHFIELD MI
48076-5545
US

V. Phone/Fax

Practice location:
  • Phone: 248-234-2392
  • Fax:
Mailing address:
  • Phone: 248-234-2393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: CHARMAIN CARTER
Title or Position: EXECUTIVE
Credential:
Phone: 248-234-2393