1669778916 NPI number — SURVIVOR GALS SPECIALTY PRODUCTS AND SALON LLC

Table of content: (NPI 1669778916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669778916 NPI number — SURVIVOR GALS SPECIALTY PRODUCTS AND SALON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURVIVOR GALS SPECIALTY PRODUCTS AND SALON 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:
SURVIVOR GALS SPECIALTY PRODUCTS FORT WORTH
Provider Other Organization Name Type Code:
3
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:
1669778916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 CUSTER RD STE 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75075-2082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-599-7677
Provider Business Mailing Address Fax Number:
972-599-1011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 8TH AVE STE 100-A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-924-8800
Provider Business Practice Location Address Fax Number:
817-924-5500
Provider Enumeration Date:
02/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GRUNWALD
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-599-7677

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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