1609658996 NPI number — REVIVE HAIR & NAIL SOLUTIONS LLC

Table of content: (NPI 1609658996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609658996 NPI number — REVIVE HAIR & NAIL SOLUTIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HAIR & NAIL SOLUTIONS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609658996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2219 34TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44709-2736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
234-804-1515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2219 34TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44709-2736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
123-480-4151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
CORNELIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
234-804-1515

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19320000X . This is a "MULTI SPECIALTY GROUP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 335E00000X . This is a "ORTHOTIC SUPPLIER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1744P3200X . This is a "PROSTHETICS CASE MANAGER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 332B00000X . This is a "MEDICAL EQUIPMENT AND MEDICAL SUPPLIES" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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