Provider Demographics
NPI:1114310281
Name:XQUISITE XTENSIONS
Entity Type:Organization
Organization Name:XQUISITE XTENSIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLOGIST
Authorized Official - Phone:704-527-0200
Mailing Address - Street 1:2805 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1801
Mailing Address - Country:US
Mailing Address - Phone:704-527-0200
Mailing Address - Fax:
Practice Address - Street 1:2805 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1801
Practice Address - Country:US
Practice Address - Phone:704-527-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC92801224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC92801OtherCOSMETOLGY