Healthcare Provider Details

I. General information

NPI: 1609755719
Provider Name (Legal Business Name): XCLUSIVELY BRANDED DBA FEDORA'S LUXE MEDICAL WIGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N MCALLISTER ST
LAKE CITY SC
29560-2421
US

IV. Provider business mailing address

117 N MCALLISTER ST
LAKE CITY SC
29560-2421
US

V. Phone/Fax

Practice location:
  • Phone: 843-956-7131
  • Fax:
Mailing address:
  • Phone: 843-956-7131
  • 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: FEDORA MCGILL
Title or Position: MANAGER
Credential:
Phone: 843-956-7131