Provider Demographics
NPI:1033825062
Name:SECRET GURU PERMANENT MAKEUP
Entity Type:Organization
Organization Name:SECRET GURU PERMANENT MAKEUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS BOARD CERT
Authorized Official - Phone:804-615-7476
Mailing Address - Street 1:3511 BELLBLUFF DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:587 SOUTHLAKE BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3096
Practice Address - Country:US
Practice Address - Phone:804-895-7616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Single Specialty