Provider Demographics
NPI:1942677273
Name:VIRGIN GIRL HAIR
Entity Type:Organization
Organization Name:VIRGIN GIRL HAIR
Other - Org Name:VIRGIN GIRL HAIR MEDICAL PROSTHESIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCILIS
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:313-799-7935
Mailing Address - Street 1:11885 E 12 MILE RD STE 200B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3469
Mailing Address - Country:US
Mailing Address - Phone:586-585-1446
Mailing Address - Fax:
Practice Address - Street 1:11885 E 12 MILE RD STE 200B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3474
Practice Address - Country:US
Practice Address - Phone:586-585-1446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI562479018Medicaid