Healthcare Provider Details

I. General information

NPI: 1609375856
Provider Name (Legal Business Name): YBOR CITY ELITE SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 E 7TH AVE STE 102
TAMPA FL
33605-3810
US

IV. Provider business mailing address

1910 E 7TH AVE STE 102
TAMPA FL
33605-3810
US

V. Phone/Fax

Practice location:
  • Phone: 813-503-0882
  • Fax:
Mailing address:
  • Phone: 813-503-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DONETTE KERR
Title or Position: MANAGER
Credential: HAIR LOSS
Phone: 813-503-0882