=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922507870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLAM CHIX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2018
-----------------------------------------------------
Last Update Date | 12/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7424 BROOK RD STE D
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23227-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-484-0292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11908 LUSBYS LN
-----------------------------------------------------
City | BRANDYWINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20613-7680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-484-0292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | GWENDOLYN RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-484-0292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 1204017518
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------