Provider Demographics
NPI:1407303605
Name:EXTRAVAGANT HAIR STUDIO
Entity Type:Organization
Organization Name:EXTRAVAGANT HAIR STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR PROSTHESIS SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BENNETTA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-323-9969
Mailing Address - Street 1:12810 MILLS BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-1381
Mailing Address - Country:US
Mailing Address - Phone:216-323-9969
Mailing Address - Fax:
Practice Address - Street 1:12810 MILLS BREEZE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1381
Practice Address - Country:US
Practice Address - Phone:216-323-9969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1420593335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier