Healthcare Provider Details

I. General information

NPI: 1366030165
Provider Name (Legal Business Name): IN AAW HAIR & BEAUTY EMPORIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 TRACY DR APT 3A
BLOOMINGTON IL
61704-7350
US

IV. Provider business mailing address

1911 TRACY DR APT 3A
BLOOMINGTON IL
61704-7350
US

V. Phone/Fax

Practice location:
  • Phone: 309-530-9415
  • Fax:
Mailing address:
  • Phone: 309-530-9415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: AKILAH WILLIAMS
Title or Position: OWNER
Credential:
Phone: 779-456-5667