Healthcare Provider Details

I. General information

NPI: 1891699195
Provider Name (Legal Business Name): EBONY LUXE HAIR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 BROADWAY ST
BLUE ISLAND IL
60406-2708
US

IV. Provider business mailing address

1510 BROADWAY ST
BLUE ISLAND IL
60406-2708
US

V. Phone/Fax

Practice location:
  • Phone: 773-603-2276
  • Fax:
Mailing address:
  • Phone: 773-603-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL

VIII. Authorized Official

Name: EBONY R PHILLIPS
Title or Position: OWNER / MANAGING MEMBER
Credential:
Phone: 773-603-2276