Healthcare Provider Details

I. General information

NPI: 1164178505
Provider Name (Legal Business Name): MEJESTIC HAIR LUXURY WIGS & EXTENSIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 MANHATTAN DR
BURLINGTON VT
05401-5544
US

IV. Provider business mailing address

70 S WINOOSKI AVE UNIT 298
BURLINGTON VT
05401-3898
US

V. Phone/Fax

Practice location:
  • Phone: 386-991-1109
  • Fax: 802-419-4847
Mailing address:
  • Phone: 386-991-1109
  • Fax: 802-419-4847

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: NAKIMA VENISE MERCER
Title or Position: OWNER
Credential:
Phone: 386-991-1109