Healthcare Provider Details

I. General information

NPI: 1972015105
Provider Name (Legal Business Name): BEAUTICIANS ON THE GO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 E CAMELBACK RD STE 130
PHOENIX AZ
85016-3449
US

IV. Provider business mailing address

PO BOX 74322
NEW RIVER AZ
85087-1006
US

V. Phone/Fax

Practice location:
  • Phone: 602-803-2827
  • Fax: 602-218-4498
Mailing address:
  • Phone: 602-803-2728
  • Fax: 602-218-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number10223435
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number10223435
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number10223435
License Number StateAZ

VIII. Authorized Official

Name: CARLA R OLIVARES
Title or Position: CEO
Credential: COSMETOLOGIST
Phone: 602-803-2827