Provider Demographics
NPI:1124373428
Name:BENEDETTA S HAIR SALON & SPA CO INC.
Entity Type:Organization
Organization Name:BENEDETTA S HAIR SALON & SPA CO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL HAIR LOSS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SANDRA
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:COMETOLOGIST
Authorized Official - Phone:586-263-9968
Mailing Address - Street 1:42302 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3620
Mailing Address - Country:US
Mailing Address - Phone:586-263-9968
Mailing Address - Fax:586-263-3947
Practice Address - Street 1:42302 HAYES RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3620
Practice Address - Country:US
Practice Address - Phone:586-263-9968
Practice Address - Fax:586-263-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2701290519335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid