Provider Demographics
NPI:1003578113
Name:INNER CITY BLEUS CLASSIC CUTZ
Entity Type:Organization
Organization Name:INNER CITY BLEUS CLASSIC CUTZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED HAIR LOSS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEYONTA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:313-475-8380
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48090-0554
Mailing Address - Country:US
Mailing Address - Phone:313-717-8952
Mailing Address - Fax:
Practice Address - Street 1:5220 E 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2358
Practice Address - Country:US
Practice Address - Phone:313-717-8952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty