Provider Demographics
NPI:1619536760
Name:IMAGE MAKER HAIR SALON AND WIG STUDIO
Entity type:Organization
Organization Name:IMAGE MAKER HAIR SALON AND WIG STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-385-0347
Mailing Address - Street 1:1033A CLAYMONT DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4481
Mailing Address - Country:US
Mailing Address - Phone:434-385-0347
Mailing Address - Fax:
Practice Address - Street 1:1033A CLAYMONT DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4481
Practice Address - Country:US
Practice Address - Phone:434-385-0347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty