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General NPI Number Information
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NPI Number | 1306615422
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Entity Type | Organization
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Legal Business Name | DIVINE BEAUTY SUPPLY INC
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Dates
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Enumeration Date | 12/29/2023
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Last Update Date | 12/29/2023
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Provider Practice Location Address
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Address Line | 2715 MACKEY PL STE 130
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City | SHREVEPORT
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State | LA
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Zip | 71118-2528
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Country | US
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Telephone | 318-657-0416
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Fax |
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Provider Business Mailing Address
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Address Line | 810 POLK ST
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City | MANSFIELD
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State | LA
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Zip | 71052-2414
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Country | US
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Telephone | 318-657-0416
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAKESHIA CARHEE
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Credential |
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Telephone | 318-773-3600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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