Healthcare Provider Details

I. General information

NPI: 1831866987
Provider Name (Legal Business Name): PURE LUXE BEAUTY AND BUNDLES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

569 SPRYFIELD RD
JACKSON MS
39212-4646
US

IV. Provider business mailing address

665 S PEAR ORCHARD RD STE 106-510
RIDGELAND MS
39157-4861
US

V. Phone/Fax

Practice location:
  • Phone: 662-590-6603
  • Fax:
Mailing address:
  • Phone: 662-590-6603
  • Fax: 662-499-2309

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: SHAVONNA LUCKETT
Title or Position: OWNER
Credential:
Phone: 662-590-6603