=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457699829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUBBLES BUBBLES BUBBLES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2013
-----------------------------------------------------
Last Update Date | 01/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 ELLSWORTH ST SUITE A
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19146-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-993-9741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1535 ELLSWORTH ST SUITE A
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19146-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MS. CRYSTAL EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-993-9741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------