Healthcare Provider Details

I. General information

NPI: 1033962725
Provider Name (Legal Business Name): CHIC GLAM SLAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17820 FIRTREE CT
CARSON CA
90746-1696
US

IV. Provider business mailing address

860 E CARSON ST STE 114
CARSON CA
90745-7948
US

V. Phone/Fax

Practice location:
  • Phone: 323-875-3099
  • Fax:
Mailing address:
  • Phone: 323-870-1413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MONICA RODRIQUEZ
Title or Position: CEO
Credential: RN,COSMETOLOGIST
Phone: 323-875-3099