=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043913551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRICELESS BEAUTY SPA,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2023
-----------------------------------------------------
Last Update Date | 04/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 JUNE BUG LN
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-358-8109
-----------------------------------------------------
Fax | 872-888-0554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 JUNE BUG LN
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-358-8109
-----------------------------------------------------
Fax | 872-888-0554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUANITA PRICE
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 972-358-8109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------