Healthcare Provider Details

I. General information

NPI: 1760260368
Provider Name (Legal Business Name): BLACK ESSENCE BEAUTY SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8359 FROST AVE
BERKELEY MO
63134-1448
US

IV. Provider business mailing address

8359 FROST AVE
BERKELEY MO
63134-1448
US

V. Phone/Fax

Practice location:
  • Phone: 314-372-9683
  • Fax:
Mailing address:
  • Phone: 314-372-9683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DANIELLE CARTER
Title or Position: OWNER
Credential: ED.D
Phone: 314-372-9683