MEDICARE: STYLES 40 SALON

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	174400000X	Specialist

General Provider Information

NPI Number	:	1497381990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STYLES 40 SALON

Provider Business Mailing Address
First Line	:	4550 GRAVOIS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-2426
Country	:	US
Telephone Number	:	314-481-6865
Fax Number	:

Provider Business Practice Location Address
First Line	:	4550 GRAVOIS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-2426
Country	:	US
Telephone Number	:	314-481-6865
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LACONIA DENISE ADAMS
Credential	:
Telephone Number	:	314-481-6865

Provider Enumeration Date	:	03/16/2020
Last Update Date	:	03/16/2020

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Directions to “STYLES 40 SALON ” Practice Location

Language	Start Address	Practice Location

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