MEDICARE: CAPTIVATING GLAM 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	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1871064055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPTIVATING GLAM SALON LLC

Provider Business Mailing Address
First Line	:	12021 DALLAS PKWY STE 600
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-3605
Country	:	US
Telephone Number	:	469-352-8411
Fax Number	:

Provider Business Practice Location Address
First Line	:	12021 DALLAS PKWY STE 600
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-3605
Country	:	US
Telephone Number	:	469-352-8411
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	D'NELL S JACKSON
Credential	:
Telephone Number	:	469-352-8411

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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