=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366931016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALON JUSTICE BEAUTY BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2018
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16300 N PARK DR STE 115
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-4721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-623-6922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24624 MELODY RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48089-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-623-6922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENOSHA H SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-623-6922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------