=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932897113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENCHANTED ESSENCE BEAUTY BOUTIQUE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2023
-----------------------------------------------------
Last Update Date | 05/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3710 GRANT DR STE A
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-786-0884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3710 GRANT DR STE A
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-786-0884
-----------------------------------------------------
Fax | 775-600-4961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LATOSHA JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-770-8023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------