Provider Demographics
NPI:1609755719
Name:XCLUSIVELY BRANDED DBA FEDORA'S LUXE MEDICA WIGS
Entity type:Organization
Organization Name:XCLUSIVELY BRANDED DBA FEDORA'S LUXE MEDICA WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FEDORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-956-7131
Mailing Address - Street 1:117 N MCALLISTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2421
Mailing Address - Country:US
Mailing Address - Phone:843-956-7131
Mailing Address - Fax:
Practice Address - Street 1:117 N MCALLISTER ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2421
Practice Address - Country:US
Practice Address - Phone:843-956-7131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier