Healthcare Provider Details

I. General information

NPI: 1487599064
Provider Name (Legal Business Name): SHOP BEAUTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18802 LIBERTY AVE
SAINT ALBANS NY
11412-1049
US

IV. Provider business mailing address

18802 LIBERTY AVE
SAINT ALBANS NY
11412-1049
US

V. Phone/Fax

Practice location:
  • Phone: 929-385-5989
  • Fax: 205-751-9233
Mailing address:
  • Phone: 929-385-5989
  • Fax: 205-751-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: SHANTELL E JAY
Title or Position: OWNER
Credential:
Phone: 929-385-5989