Provider Demographics
NPI:1780034454
Name:VOLUMINOUS VIRGIN HAIR BOUTIQUE
Entity Type:Organization
Organization Name:VOLUMINOUS VIRGIN HAIR BOUTIQUE
Other - Org Name:SOU CONSULTANTS
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-877-7797
Mailing Address - Street 1:445 EG.MILES PARKWAY
Mailing Address - Street 2:207
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-9623
Mailing Address - Country:US
Mailing Address - Phone:912-877-7797
Mailing Address - Fax:
Practice Address - Street 1:445 ELMA G MILES PKWY
Practice Address - Street 2:207
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3230
Practice Address - Country:US
Practice Address - Phone:912-877-7797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20725332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies