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General NPI Number Information
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NPI Number | 1730424177
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Entity Type | Organization
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Legal Business Name | STYLING ICONZ HAIR REPLACEMENT CLINIC
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Dates
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Enumeration Date | 12/11/2012
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Last Update Date | 12/11/2012
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Provider Practice Location Address
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Address Line | 7309 E INDEPENDENCE BLVD 25
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City | CHARLOTTE
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State | NC
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Zip | 28227-9476
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Country | US
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Telephone | 704-310-8893
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Fax |
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Provider Business Mailing Address
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Address Line | 7309 E INDEPENDENCE BLVD STE 25
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City | CHARLOTTE
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State | NC
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Zip | 28227-9439
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Country | US
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Telephone | 704-310-8893
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANGEL BLOSSOM MCGOWAN-ROBINSON
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Credential | COS. MD
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Telephone | 704-310-8893
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 185683
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License Number State | NC
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