Healthcare Provider Details

I. General information

NPI: 1346754488
Provider Name (Legal Business Name): CHANEL'S HAIR BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8818 LA MESA BLVD
LA MESA CA
91942-5407
US

IV. Provider business mailing address

8818 LA MESA BLVD
LA MESA CA
91942-5407
US

V. Phone/Fax

Practice location:
  • Phone: 619-200-3186
  • Fax:
Mailing address:
  • Phone: 619-200-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS RHODEN
Title or Position: OWNER
Credential:
Phone: 619-200-3186