Healthcare Provider Details

I. General information

NPI: 1043094899
Provider Name (Legal Business Name): HAIR REPLICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W DEKALB ST # C
CAMDEN SC
29020-4259
US

IV. Provider business mailing address

905 W DEKALB ST # C
CAMDEN SC
29020-4259
US

V. Phone/Fax

Practice location:
  • Phone: 803-549-2553
  • Fax:
Mailing address:
  • Phone: 803-549-2553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CELESTINE D LEE
Title or Position: OWNER
Credential: HAIR LOSS SPECIALIST
Phone: 803-549-2553