Healthcare Provider Details

I. General information

NPI: 1932897113
Provider Name (Legal Business Name): ENCHANTED ESSENCE BEAUTY BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 GRANT DR STE A
RENO NV
89509-5317
US

IV. Provider business mailing address

3710 GRANT DR STE A
RENO NV
89509-5317
US

V. Phone/Fax

Practice location:
  • Phone: 775-786-0884
  • Fax:
Mailing address:
  • Phone: 775-786-0884
  • Fax: 775-600-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. LATOSHA JACKSON
Title or Position: OWNER
Credential:
Phone: 775-770-8023