=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720582596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MZCOLA BEAUTY BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2018
-----------------------------------------------------
Last Update Date | 03/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 723 SHADY ACRES LN
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-838-4633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 723 SHADY ACRES LN
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-838-4633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEA'SHANAY DORRIS
-----------------------------------------------------
Credential | COSMETOLOGY
-----------------------------------------------------
Telephone | 708-838-4633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 011.301973
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------