Provider Demographics
NPI:1477233112
Name:MY HAIR BOUTIQUE LLC
Entity Type:Organization
Organization Name:MY HAIR BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:UNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-501-4023
Mailing Address - Street 1:209 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-2354
Mailing Address - Country:US
Mailing Address - Phone:215-501-4023
Mailing Address - Fax:
Practice Address - Street 1:400 W ROUTE 38 UNIT 1460
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3219
Practice Address - Country:US
Practice Address - Phone:856-386-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-18
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier