Healthcare Provider Details

I. General information

NPI: 1376357913
Provider Name (Legal Business Name): BEAUTY GREEN SALON & HAIR EXTENSIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3812 SW 8TH ST
CORAL GABLES FL
33134-3002
US

IV. Provider business mailing address

3812 SW 8TH ST
CORAL GABLES FL
33134-3002
US

V. Phone/Fax

Practice location:
  • Phone: 786-607-3698
  • Fax:
Mailing address:
  • Phone: 786-607-3698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: YSDALY THIELEN
Title or Position: PRESIDENT
Credential:
Phone: 786-607-3698