Provider Demographics
NPI:1164028437
Name:GLAM D BY SISTERS
Entity Type:Organization
Organization Name:GLAM D BY SISTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAZZAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-610-1715
Mailing Address - Street 1:3242 E DESERT INN RD STE 13
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3337
Mailing Address - Country:US
Mailing Address - Phone:702-610-1715
Mailing Address - Fax:
Practice Address - Street 1:3242 E DESERT INN RD STE 13
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3337
Practice Address - Country:US
Practice Address - Phone:702-610-1715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health