Healthcare Provider Details

I. General information

NPI: 1598526931
Provider Name (Legal Business Name): MIRROR GAZE BEAUTY BAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6631B OLD STATESVILLE RD
CHARLOTTE NC
28269-1733
US

IV. Provider business mailing address

5432 VIEWMONT DR
CHARLOTTE NC
28215-1705
US

V. Phone/Fax

Practice location:
  • Phone: 704-750-9290
  • Fax:
Mailing address:
  • Phone: 470-430-2949
  • 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

VIII. Authorized Official

Name: ALEXIS HALL
Title or Position: HAIR REPLACEMENT SPECIALIST
Credential:
Phone: 704-750-9290