Provider Demographics
NPI:1851857189
Name:FAIRYTALE HAIR L.L.C
Entity Type:Organization
Organization Name:FAIRYTALE HAIR L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-650-3405
Mailing Address - Street 1:192 WILLIAMSBURG CV
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-9433
Mailing Address - Country:US
Mailing Address - Phone:501-650-3405
Mailing Address - Fax:
Practice Address - Street 1:1802 S HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-5511
Practice Address - Country:US
Practice Address - Phone:501-605-3405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty