Healthcare Provider Details

I. General information

NPI: 1114310281
Provider Name (Legal Business Name): XQUISITE XTENSIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 SOUTH BLVD
CHARLOTTE NC
28209-1801
US

IV. Provider business mailing address

2805 SOUTH BLVD
CHARLOTTE NC
28209-1801
US

V. Phone/Fax

Practice location:
  • Phone: 704-527-0200
  • Fax:
Mailing address:
  • Phone: 704-527-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberNC92801
License Number StateNC

VIII. Authorized Official

Name: DANA CANNON
Title or Position: OWNER
Credential: COSMETOLOGIST
Phone: 704-527-0200