Healthcare Provider Details

I. General information

NPI: 1952817272
Provider Name (Legal Business Name): BEAUTIQUE SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1186 S 2ND ST
SAN JOSE CA
95112-5914
US

IV. Provider business mailing address

1186 S 2ND ST
SAN JOSE CA
95112-5914
US

V. Phone/Fax

Practice location:
  • Phone: 408-460-8070
  • Fax:
Mailing address:
  • Phone: 408-460-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberKK482064
License Number StateCA

VIII. Authorized Official

Name: MRS. SHARELLE NICOLE LOUDD
Title or Position: CEO
Credential: CERTIFIED HAIR-LOSS
Phone: 408-460-8070