Healthcare Provider Details

I. General information

NPI: 1275367195
Provider Name (Legal Business Name): VINTAGE HAIR SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 05/09/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 E INDEPENDENCE BLVD # 53
CHARLOTTE NC
28205-7034
US

IV. Provider business mailing address

2000 ST LUKE ST
CHARLOTTE NC
28216-4837
US

V. Phone/Fax

Practice location:
  • Phone: 704-236-3156
  • Fax:
Mailing address:
  • Phone: 704-236-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PATRICE Y BIDGOOD
Title or Position: OWNER
Credential: SPECIALIST
Phone: 704-236-3156