Healthcare Provider Details

I. General information

NPI: 1780134965
Provider Name (Legal Business Name): HAIRFANATIC BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2757 LAUREL ST SUITE 3
COLUMBIA SC
29204-2037
US

IV. Provider business mailing address

2757 LAUREL ST SUITE 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 Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARANDA BROWN DAVIS
Title or Position: HAIR LOSS SPECIALIST
Credential: CERTIFIED HAIR LOSS
Phone: 803-730-0231