Healthcare Provider Details

I. General information

NPI: 1003383233
Provider Name (Legal Business Name): BOMBEAUTY SUPPLY AND SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 LAKE SHORE DR UNIT A
INDIANAPOLIS IN
46205
US

IV. Provider business mailing address

8421 WEEPING CHERRY LANE
FT WORTH TX
76140
US

V. Phone/Fax

Practice location:
  • Phone: 817-721-5008
  • Fax:
Mailing address:
  • Phone: 817-721-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: ANDREA SCOTT
Title or Position: OWNER
Credential:
Phone: 317-523-6475