Organization
PURE GOLD LUXZ HAIR BEAUTY LUXURY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
FATIA RUSSELL CERTIFIED HAIR LOSS (OWNER)
(201) 892-2678
Entity
Organization
Contact information
Practice address
508 OWEN DR, FAYETTEVILLE, NC 28304-3417
(910) 479-6214
Mailing address
6245 LAKEHAVEN DR, FAYETTEVILLE, NC 28304-0610
(201) 892-2678
Taxonomy
Speciality
Code
Description
License number
State
224P00000X
Prosthetist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1356843379
—
NC
Enumeration date
04/30/2019
Last updated
08/31/2019
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