Healthcare Provider Details

I. General information

NPI: 1578062055
Provider Name (Legal Business Name): DIVINE BEAUTY & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 08/16/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD STE 100
BALTIMORE MD
21207-5284
US

IV. Provider business mailing address

8125 SUBET RD
WINDSOR MILL MD
21244-2973
US

V. Phone/Fax

Practice location:
  • Phone: 410-304-3127
  • Fax:
Mailing address:
  • Phone: 443-744-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TYRAHNA JEFFERSON
Title or Position: CEO/OWNER
Credential: CERTIFIED HAIR LOSS
Phone: 410-304-3127