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General NPI Number Information
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NPI Number | 1902546187
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Entity Type | Organization
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Legal Business Name | DIVINE LASH & BEAUTY BAR
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Dates
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Enumeration Date | 03/29/2022
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Last Update Date | 08/09/2023
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Provider Practice Location Address
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Address Line | 10520 N BAEHR RD STE M
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City | MEQUON
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State | WI
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Zip | 53092-6701
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Country | US
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Telephone | 262-417-8385
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Fax | 414-202-6350
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Provider Business Mailing Address
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Address Line | 10520 N BAEHR RD STE M
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City | MEQUON
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State | WI
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Zip | 53092-6701
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Country | US
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Telephone | 262-417-8385
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Fax | 414-202-6350
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Authorized Official
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Title or Position | OWNER/AESTTHETICIAN
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Name | ASHLEY MOORE
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Credential |
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Telephone | 414-202-6350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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