Healthcare Provider Details

I. General information

NPI: 1124309919
Provider Name (Legal Business Name): BEDAZZLED SALON AND SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11708 MAIN ST
ROSCOE IL
61073-9566
US

IV. Provider business mailing address

11708 MAIN ST
ROSCOE IL
61073-9566
US

V. Phone/Fax

Practice location:
  • Phone: 815-389-4965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY JENKINS
Title or Position: OWNER
Credential:
Phone: 815-389-4965