Healthcare Provider Details

I. General information

NPI: 1619429685
Provider Name (Legal Business Name): REVAMPED BEAUTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 ENSLEY 5 POINTS W AVE
BIRMINGHAM AL
35218-2853
US

IV. Provider business mailing address

1024 KERRY DR
CALERA AL
35040-5512
US

V. Phone/Fax

Practice location:
  • Phone: 205-478-7518
  • Fax:
Mailing address:
  • Phone: 205-478-7518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: BRITTNEY BASS-GRAY
Title or Position: FOUNDER
Credential:
Phone: 205-478-7518