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General NPI Number Information
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NPI Number | 1467170324
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Entity Type | Organization
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Legal Business Name | PHIVE STAR HAIR BOUTIQUE LLC
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Dates
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Enumeration Date | 08/17/2022
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Last Update Date | 08/17/2022
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Provider Practice Location Address
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Address Line | 320 N MAGNOLIA AVE STE A1
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City | ORLANDO
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State | FL
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Zip | 32801-1650
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Country | US
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Telephone | 321-374-1460
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Fax |
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Provider Business Mailing Address
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Address Line | 320 N MAGNOLIA AVE STE A1
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City | ORLANDO
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State | FL
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Zip | 32801-1650
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Country | US
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Telephone | 321-374-1460
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KATEAU CERISME
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Credential |
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Telephone | 321-374-1460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number |
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License Number State |
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