Provider Demographics
NPI:1467919670
Name:ILLUSION HAIR INDUSTRIES LLC
Entity Type:Organization
Organization Name:ILLUSION HAIR INDUSTRIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:OLAJIDE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-471-5170
Mailing Address - Street 1:2728 DAVIE BLVD UNIT 73
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-2927
Mailing Address - Country:US
Mailing Address - Phone:954-471-5170
Mailing Address - Fax:
Practice Address - Street 1:540 NW 165TH STREET RD STE 109
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6304
Practice Address - Country:US
Practice Address - Phone:954-471-5170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier