Healthcare Provider Details

I. General information

NPI: 1669732301
Provider Name (Legal Business Name): MULBERRY WELLNESS SALON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 MULBERRY ST
MONTGOMERY AL
36106-1524
US

IV. Provider business mailing address

1734 MULBERRY ST
MONTGOMERY AL
36106-1524
US

V. Phone/Fax

Practice location:
  • Phone: 334-819-7249
  • Fax: 334-819-7249
Mailing address:
  • Phone: 334-819-7249
  • Fax: 334-819-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number161733
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number161733
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number39089
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number39089
License Number StateAL

VIII. Authorized Official

Name: MS. RAMONA J WASHINGTON
Title or Position: MASTER COSMETOLOGIST/OWNER
Credential: CERTIFIED HAIR LOSS
Phone: 334-868-5189