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General NPI Number Information
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NPI Number | 1053506121
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Entity Type | Organization
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Legal Business Name | MERCER BEAUTY SUPPLY
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 07/16/2008
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Provider Practice Location Address
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Address Line | 1016 SW D AVE
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City | LAWTON
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State | OK
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Zip | 73501
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Country | US
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Telephone | 580-353-0690
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Fax |
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Provider Business Mailing Address
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Address Line | 1016 SW D AVE
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City | LAWTON
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State | OK
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Zip | 73501
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Country | US
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Telephone | 580-353-0690
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. IVA L BLACK
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Credential |
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Telephone | 580-353-0690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225000000X
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Taxonomy Name | Orthotic Fitter
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License Number | 22498 001
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 22498 001
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License Number State | OK
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