Healthcare Provider Details

I. General information

NPI: 1063901072
Provider Name (Legal Business Name): ELITE BARBER SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 01/06/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 CENTRAL AVENUE SUITE E
SUMMERVILLE SC
29483
US

IV. Provider business mailing address

117 NATCHEZ KUSSO ROAD
RIDGEVILLE SC
29472
US

V. Phone/Fax

Practice location:
  • Phone: 843-475-1033
  • Fax:
Mailing address:
  • Phone: 843-475-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK NUGENT HILL
Title or Position: OWNER/OPERATOR
Credential:
Phone: 843-475-1033