Healthcare Provider Details

I. General information

NPI: 1518359041
Provider Name (Legal Business Name): REBECCA SELDRIA WOODEN COSMOTOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S COOPER ST STE 36
ARLINGTON TX
76015-4159
US

IV. Provider business mailing address

PO BOX 182232
ARLINGTON TX
76096-2232
US

V. Phone/Fax

Practice location:
  • Phone: 682-465-7465
  • Fax: 801-720-4753
Mailing address:
  • Phone: 682-465-7465
  • Fax: 801-720-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1420474
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: