Provider Demographics
NPI:1467771592
Name:SPECIAL EFFECT HAIR STUDIO
Entity Type:Organization
Organization Name:SPECIAL EFFECT HAIR STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COSMETOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-265-0669
Mailing Address - Street 1:1454 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1343
Mailing Address - Country:US
Mailing Address - Phone:617-265-0669
Mailing Address - Fax:
Practice Address - Street 1:1454 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1343
Practice Address - Country:US
Practice Address - Phone:617-265-0669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1122002335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier