Healthcare Provider Details

I. General information

NPI: 1306400759
Provider Name (Legal Business Name): PURE GOLD LUXZ HAIR BEAUTY LUXURY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 08/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 OWEN DR
FAYETTEVILLE NC
28304-3417
US

IV. Provider business mailing address

6245 LAKEHAVEN DR
FAYETTEVILLE NC
28304-0610
US

V. Phone/Fax

Practice location:
  • Phone: 910-479-6214
  • Fax:
Mailing address:
  • Phone: 201-892-2678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: FATIA RUSSELL
Title or Position: OWNER
Credential: CERTIFIED HAIR LOSS
Phone: 201-892-2678