=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932803426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EPICENTER SALON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2023
-----------------------------------------------------
Last Update Date | 03/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 GLEN OAK DR
-----------------------------------------------------
City | EAST AMHERST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14051-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-713-0094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 GLEN OAK DR
-----------------------------------------------------
City | EAST AMHERST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14051-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-713-0094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEVEN PRESTON DANIELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-713-0094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------