Provider Demographics
NPI:1114468428
Name:EXODUS HAIR & NAIL STUDIO LLC
Entity Type:Organization
Organization Name:EXODUS HAIR & NAIL STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:586-242-5729
Mailing Address - Street 1:21526 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-242-5729
Mailing Address - Fax:
Practice Address - Street 1:21526 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2210
Practice Address - Country:US
Practice Address - Phone:586-242-5729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332924-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty