Provider Demographics
NPI:1588233944
Name:EVERLASTING IMPRESSIONS HAIR RESTORATION CLINIC
Entity Type:Organization
Organization Name:EVERLASTING IMPRESSIONS HAIR RESTORATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-773-6581
Mailing Address - Street 1:13246 DESIRE ST
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090-4328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:321 NORTH CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2988
Practice Address - Country:US
Practice Address - Phone:225-265-6068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies