Provider Demographics
NPI:1184270894
Name:INDIGO HAIR INNOVATIONS LLC
Entity type:Organization
Organization Name:INDIGO HAIR INNOVATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TASHEBA
Authorized Official - Middle Name:SUZANNIE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-433-7506
Mailing Address - Street 1:641 NEW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1318
Mailing Address - Country:US
Mailing Address - Phone:860-990-1565
Mailing Address - Fax:
Practice Address - Street 1:641 NEW PARK AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1318
Practice Address - Country:US
Practice Address - Phone:860-990-1565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1744P3200XMedicaid