=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942946058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURPLE BUTTERFLY A V STEAM BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2022
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8214 POZZI RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-619-3515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8214 POZZI RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-619-3515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OPERATOR
-----------------------------------------------------
Name | KEISHA LYNETTE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-619-3515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------