1720558893 NPI number — BROADBAND INNOVATION GROUP

Table of content: (NPI 1720558893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720558893 NPI number — BROADBAND INNOVATION GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADBAND INNOVATION GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INNOVATION HAIR CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720558893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 HAY ST STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28301-5581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-824-2872
Provider Business Mailing Address Fax Number:
910-378-1962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2915 RAEFORD RD STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28303-5491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-378-1966
Provider Business Practice Location Address Fax Number:
910-378-1962
Provider Enumeration Date:
11/30/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAMUELS
Authorized Official First Name:
LEVI
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF BUSINESS & OPERATIONS
Authorized Official Telephone Number:
910-824-2872

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)