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General NPI Number Information
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NPI Number | 1033825062
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Entity Type | Organization
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Legal Business Name | SECRET GURU PERMANENT MAKEUP
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Dates
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Enumeration Date | 01/24/2023
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Last Update Date | 01/24/2023
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Provider Practice Location Address
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Address Line | 587 SOUTHLAKE BLVD STE A
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-3096
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Country | US
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Telephone | 804-895-7616
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Fax |
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Provider Business Mailing Address
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Address Line | 3511 BELLBLUFF DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23237-1002
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTINA SOUTHERS
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Credential | MASTERS BOARD CERT.
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Telephone | 804-615-7476
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZA2600X
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Taxonomy Name | Medical Art Specialist/Technologist
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License Number |
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License Number State |
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