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General NPI Number Information
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NPI Number | 1033772868
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Entity Type | Organization
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Legal Business Name | PLUSH ROSE A BLOWOUT BAR SALON INC.
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 12/16/2020
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Provider Practice Location Address
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Address Line | 2534 WYNNTON RD STE B
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City | COLUMBUS
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State | GA
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Zip | 31906-2180
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Country | US
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Telephone | 706-317-2115
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Fax |
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Provider Business Mailing Address
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Address Line | 2534 WYNNTON RD STE B
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City | COLUMBUS
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State | GA
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Zip | 31906-2180
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Country | US
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Telephone | 706-317-2115
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. KIMBERLY SHERELL GORE
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Credential |
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Telephone | 470-898-9454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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