Healthcare Provider Details

I. General information

NPI: 1962905182
Provider Name (Legal Business Name): FABULOUSLY MADE SALON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/20/2021
Certification Date: 03/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8913 REGENTS PARK DR STE 620
TAMPA FL
33647-3077
US

IV. Provider business mailing address

6037 OSPREY LAKE CIR
RIVERVIEW FL
33578-3959
US

V. Phone/Fax

Practice location:
  • Phone: 813-444-3229
  • Fax:
Mailing address:
  • Phone: 813-444-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHANNA AMARANTE
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential:
Phone: 813-444-3229