Provider Demographics
NPI:1205676160
Name:HAIRFANATIC BOUTIQUE LLC
Entity type:Organization
Organization Name:HAIRFANATIC BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPECIALIST-OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:HAIRLOSS SPECIALIST
Authorized Official - Phone:803-218-9713
Mailing Address - Street 1:2757 LAUREL STREET SUITE 3
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-218-9713
Mailing Address - Fax:
Practice Address - Street 1:2757 LAUREL STREET SUITE 3
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-218-9713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies