Healthcare Provider Details

I. General information

NPI: 1104368968
Provider Name (Legal Business Name): MARANDA BROWN DAVIS HAIRLOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2757 LAUREL ST 3
COLUMBIA SC
29204-2037
US

IV. Provider business mailing address

2757 LAUREL ST 3
COLUMBIA SC
29204-2037
US

V. Phone/Fax

Practice location:
  • Phone: 803-730-0231
  • Fax:
Mailing address:
  • Phone: 803-730-0231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1744P3200X
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: