Provider Demographics
NPI:1598777831
Name:HI FASHION BOUTIQUE
Entity Type:Organization
Organization Name:HI FASHION BOUTIQUE
Other - Org Name:HI FASHION WIGS BOUTIQUE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:DEL SOCCORRO
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OPERATOR, LICENSED
Authorized Official - Phone:210-732-7070
Mailing Address - Street 1:4522 FREDERICKSBURG RD
Mailing Address - Street 2:A35
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-6521
Mailing Address - Country:US
Mailing Address - Phone:210-732-7070
Mailing Address - Fax:
Practice Address - Street 1:4522 FREDERICKSBURG RD
Practice Address - Street 2:A35
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6521
Practice Address - Country:US
Practice Address - Phone:210-732-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2011-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX691-021335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX691-021OtherTEXAS COSMETOLOGY