Healthcare Provider Details

I. General information

NPI: 1194319665
Provider Name (Legal Business Name): EBK BEAUTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9283 SAN JOSE BLVD
JACKSONVILLE FL
32257-5584
US

IV. Provider business mailing address

9283 SAN JOSE BLVD
JACKSONVILLE FL
32257-5584
US

V. Phone/Fax

Practice location:
  • Phone: 904-392-1278
  • Fax:
Mailing address:
  • Phone: 904-392-1278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. KOBE ELLIS
Title or Position: CEO
Credential:
Phone: 904-392-1278