Healthcare Provider Details

I. General information

NPI: 1578078663
Provider Name (Legal Business Name): EURSEL NICOLE ASHFORD COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date: 03/19/2018
Reactivation Date: 04/25/2018

III. Provider practice location address

128 S ASSEMBLY ST
COLUMBIA SC
29201-4545
US

IV. Provider business mailing address

241 ROSEBROOK DR
HOPKINS SC
29061-8389
US

V. Phone/Fax

Practice location:
  • Phone: 803-397-4216
  • Fax: 803-232-7944
Mailing address:
  • Phone: 803-397-4216
  • Fax: 803-232-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number62684
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: