Provider Demographics
NPI:1972043719
Name:ROYAL GLYTZ HAIR REPLACEMET
Entity Type:Organization
Organization Name:ROYAL GLYTZ HAIR REPLACEMET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-849-4422
Mailing Address - Street 1:500 N REILLY RD STE 122
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-2452
Mailing Address - Country:US
Mailing Address - Phone:910-849-4422
Mailing Address - Fax:
Practice Address - Street 1:500 N REILLY RD STE 122
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-2452
Practice Address - Country:US
Practice Address - Phone:910-849-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC88537335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier