Provider Demographics
NPI:1295307387
Name:LUSH HAIR AFFAIR
Entity type:Organization
Organization Name:LUSH HAIR AFFAIR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CRANIAL PROSTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-729-6940
Mailing Address - Street 1:136-4 FORUM DRIVE
Mailing Address - Street 2:#1055
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:803-710-7307
Practice Address - Street 1:136-4 FORUM DRIVE
Practice Address - Street 2:#1055
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-427-9202
Practice Address - Fax:803-710-7307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier