Healthcare Provider Details

I. General information

NPI: 1225917719
Provider Name (Legal Business Name): EXTENSIONS & HAIR BOUDOIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7705 SAINT ANDREWS RD BLDG B
IRMO SC
29063-2835
US

IV. Provider business mailing address

7705 SAINT ANDREWS RD BLDG B
IRMO SC
29063-2835
US

V. Phone/Fax

Practice location:
  • Phone: 803-445-6931
  • Fax:
Mailing address:
  • Phone: 803-445-6931
  • 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: ERICA R WIGGINS
Title or Position: OWNER
Credential:
Phone: 803-445-6931