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General NPI Number Information
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NPI Number | 1407303605
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Entity Type | Organization
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Legal Business Name | EXTRAVAGANT HAIR STUDIO
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Dates
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Enumeration Date | 09/06/2016
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Last Update Date | 09/06/2016
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Provider Practice Location Address
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Address Line | 12810 MILLS BREEZE DR
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City | HOUSTON
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State | TX
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Zip | 77070-1381
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Country | US
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Telephone | 216-323-9969
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Fax |
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Provider Business Mailing Address
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Address Line | 12810 MILLS BREEZE DR
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City | HOUSTON
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State | TX
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Zip | 77070-1381
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Country | US
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Telephone | 216-323-9969
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Fax |
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Authorized Official
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Title or Position | HAIR PROSTHESIS SPECIALIST
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Name | MS. BENNETTA JOYCE REYNOLDS
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Credential |
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Telephone | 216-323-9969
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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 | 1420593
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License Number State | TX
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