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General NPI Number Information
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NPI Number | 1164178505
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Entity Type | Organization
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Legal Business Name | MEJESTIC HAIR LUXURY WIGS & EXTENSIONS LLC
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Dates
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Enumeration Date | 02/24/2022
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Last Update Date | 02/24/2022
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Provider Practice Location Address
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Address Line | 329 MANHATTAN DR
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City | BURLINGTON
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State | VT
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Zip | 05401-5544
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Country | US
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Telephone | 386-991-1109
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Fax | 802-419-4847
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Provider Business Mailing Address
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Address Line | 70 S WINOOSKI AVE UNIT 298
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City | BURLINGTON
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State | VT
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Zip | 05401-3898
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Country | US
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Telephone | 386-991-1109
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Fax | 802-419-4847
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Authorized Official
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Title or Position | OWNER
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Name | NAKIMA VENISE MERCER
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Credential |
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Telephone | 386-991-1109
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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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