Healthcare Provider Details

I. General information

NPI: 1093153264
Provider Name (Legal Business Name): BEAUTY VENOM HAIR LOSS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 N DURANGO DR SUITE 125
LAS VEGAS NV
89131-8000
US

IV. Provider business mailing address

7785 N DURANGO DR SUITE 125
LAS VEGAS NV
89131-8000
US

V. Phone/Fax

Practice location:
  • Phone: 702-658-8866
  • Fax:
Mailing address:
  • Phone: 702-658-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateGA

VIII. Authorized Official

Name: ASHLEY LYKE
Title or Position: CERTIFIED TRICHOLOGY PRACTICTIONER
Credential: B.A.MGMT/ NTTI GRAD
Phone: 702-807-1498