Healthcare Provider Details

I. General information

NPI: 1992371892
Provider Name (Legal Business Name): EXTENSION COUTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17600 W 8 MILE RD
SOUTHFIELD MI
48075-4305
US

IV. Provider business mailing address

PO BOX 39706
REDFORD MI
48239-0706
US

V. Phone/Fax

Practice location:
  • Phone: 248-973-7340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CHARMAINE BRYANT
Title or Position: CEO
Credential:
Phone: 313-205-9545