Healthcare Provider Details

I. General information

NPI: 1467170324
Provider Name (Legal Business Name): PHIVE STAR HAIR BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MAGNOLIA AVE STE A1
ORLANDO FL
32801-1650
US

IV. Provider business mailing address

320 N MAGNOLIA AVE STE A1
ORLANDO FL
32801-1650
US

V. Phone/Fax

Practice location:
  • Phone: 321-374-1460
  • Fax:
Mailing address:
  • Phone: 321-374-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: KATEAU CERISME
Title or Position: CEO
Credential:
Phone: 321-374-1460