MEDICARE: ELEGANT BEAUTY SUPPLIES # 11 INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1427395318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEGANT BEAUTY SUPPLIES # 11 INC

Provider Business Mailing Address
First Line	:	1209 S 30TH AVE
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-5631
Country	:	US
Telephone Number	:	954-921-9129
Fax Number	:

Provider Business Practice Location Address
First Line	:	2099 W ATLANTIC BLVD
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-2757
Country	:	US
Telephone Number	:	954-921-9129
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. BASHIR MALOUF
Credential	:
Telephone Number	:	305-202-1224

Provider Enumeration Date	:	01/11/2013
Last Update Date	:	01/11/2013

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