Healthcare Provider Details

I. General information

NPI: 1710494802
Provider Name (Legal Business Name): INSPIRED DESIGNS HAIR SALON & BARBERSHOP & SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 E STAN SCHLUETER LOOP STE 201
KILLEEN TX
76542-4554
US

IV. Provider business mailing address

5214 SILTSTONE LOOP
KILLEEN TX
76542-5815
US

V. Phone/Fax

Practice location:
  • Phone: 254-220-9921
  • Fax: 254-731-4232
Mailing address:
  • Phone: 254-220-9921
  • Fax: 254-731-4232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1178165
License Number StateTX

VIII. Authorized Official

Name: MRS. DERINA LAVETTE GARCIA
Title or Position: CERTIFIED HAIR REPLACEMENT SPECIALI
Credential: CHRS
Phone: 254-220-9921