Organization
VIRGIN GIRL HAIR
Active
Other names
Virgin Girl Hair Medical Prosthesis
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL MARCILIS II (OWNER)
(313) 799-7935
Entity
Organization
Contact information
Practice address
11885 E 12 MILE RD STE 200B, WARREN, MI 48093-3474
(586) 585-1446
Mailing address
11885 E 12 MILE RD STE 200B, WARREN, MI 48093-3469
(586) 585-1446
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
562479018
—
MI
Enumeration date
08/21/2015
Last updated
12/30/2015
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