MEDICARE: A DIVA'S DREAM SALON 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	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1780197285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A DIVA'S DREAM SALON LLC

Provider Business Mailing Address
First Line	:	23054 EMERY RD
Second Line	:
City	:	WARRENSVILLE HEIGHTS
State	:	OH
Zip	:	44128-5135
Country	:	US
Telephone Number	:	216-292-1313
Fax Number	:

Provider Business Practice Location Address
First Line	:	23054 EMERY RD
Second Line	:
City	:	WARRENSVILLE HEIGHTS
State	:	OH
Zip	:	44128-5135
Country	:	US
Telephone Number	:	216-292-1313
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED HAIR LOSS SPECIALIS
Name	:	MRS. REESA LANETTE BROWN
Credential	:	CERTIFIED HAIR LOSS
Telephone Number	:	216-292-1313

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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