=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871774414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUTYWISE HOLISTIC SHOP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-243-6778
-----------------------------------------------------
Fax | 305-243-6530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18252 SW 94 COURT
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-588-1145
-----------------------------------------------------
Fax | 305-243-6530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. REBECKA SANCHEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-588-1145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------