Provider Demographics
NPI:1720558893
Name:BROADBAND INNOVATION GROUP
Entity Type:Organization
Organization Name:BROADBAND INNOVATION GROUP
Other - Org Name:INNOVATION HAIR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF BUSINESS & OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:910-824-2872
Mailing Address - Street 1:201 HAY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5581
Mailing Address - Country:US
Mailing Address - Phone:910-824-2872
Mailing Address - Fax:910-378-1962
Practice Address - Street 1:2915 RAEFORD RD STE 203
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5491
Practice Address - Country:US
Practice Address - Phone:910-378-1966
Practice Address - Fax:910-378-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies