Provider Demographics
NPI:1548991888
Name:THE HAIR DIVE LLC
Entity type:Organization
Organization Name:THE HAIR DIVE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:727-265-0013
Mailing Address - Street 1:2822 54TH AVE S # 213
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-4610
Mailing Address - Country:US
Mailing Address - Phone:727-265-0013
Mailing Address - Fax:
Practice Address - Street 1:6920 22ND AVE N STE 120
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3920
Practice Address - Country:US
Practice Address - Phone:727-265-0013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier