Healthcare Provider Details

I. General information

NPI: 1003578113
Provider Name (Legal Business Name): INNER CITY BLEUS CLASSIC CUTZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 E 7 MILE RD
DETROIT MI
48234-2358
US

IV. Provider business mailing address

PO BOX 554
WARREN MI
48090-0554
US

V. Phone/Fax

Practice location:
  • Phone: 313-717-8952
  • Fax:
Mailing address:
  • Phone: 313-717-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: DEYONTA NEWSOME
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: HAIR LOSS SPECIALIST
Phone: 313-475-8380