Provider Demographics
NPI:1366763971
Name:EXCLUSIVE GROOMING & HAIR REPLACEMENT CENTER
Entity type:Organization
Organization Name:EXCLUSIVE GROOMING & HAIR REPLACEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-500-1346
Mailing Address - Street 1:PO BOX 5274
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-5274
Mailing Address - Country:US
Mailing Address - Phone:704-500-1346
Mailing Address - Fax:
Practice Address - Street 1:1414 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-7925
Practice Address - Country:US
Practice Address - Phone:704-500-1346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC63952335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier