MEDICARE: TIFFANI CHANELS BEAUTY SUPPLY, LLC

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	:	1558798512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIFFANI CHANELS BEAUTY SUPPLY, LLC

Provider Business Mailing Address
First Line	:	330 RAYFORD RD
Second Line	:	211
City	:	SPRING
State	:	TX
Zip	:	77386-1980
Country	:	US
Telephone Number	:	317-755-9963
Fax Number	:

Provider Business Practice Location Address
First Line	:	2578 S LOOP W
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2634
Country	:	US
Telephone Number	:	317-755-9963
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIFFANI SPELLER
Credential	:
Telephone Number	:	317-755-9963

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	10/03/2013

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