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General NPI Number Information
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NPI Number | 1033783501
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Entity Type | Organization
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Legal Business Name | LACED BY SHEA INC.
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Dates
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Enumeration Date | 05/18/2021
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Last Update Date | 05/18/2021
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Provider Practice Location Address
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Address Line | 9949 E INDEPENDENCE BLVD # 20
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City | MATTHEWS
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State | NC
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Zip | 28105-4665
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Country | US
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Telephone | 704-960-7003
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Fax |
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Provider Business Mailing Address
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Address Line | 11433 CALLAHAN MILL DR
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City | CHARLOTTE
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State | NC
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Zip | 28213-5884
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Country | US
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Telephone | 704-960-7003
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Fax |
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Authorized Official
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Title or Position | SALON OWNER
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Name | SHEA FELDER
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Credential | COSMETOLOGIST
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Telephone | 704-960-7003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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