=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497385454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHENOMENAL HAIR REPLACEMENT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2020
-----------------------------------------------------
Last Update Date | 01/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9400 TWO NOTCH RD STE E1
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-5946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-477-5243
-----------------------------------------------------
Fax | 803-753-4353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9400 TWO NOTCH RD STE E1
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-5946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-477-5243
-----------------------------------------------------
Fax | 803-753-4353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NON SURGICAL HAIR REPLACEMENT
-----------------------------------------------------
Name | CATHY J MACK
-----------------------------------------------------
Credential | SPECIALIST
-----------------------------------------------------
Telephone | 803-477-5243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------