Provider Demographics
NPI:1275218547
Name:EXTREME BEAUTY SUPPLY & RETAIL, LLC
Entity Type:Organization
Organization Name:EXTREME BEAUTY SUPPLY & RETAIL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:FALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-327-8708
Mailing Address - Street 1:23 W MARKET ST UNIT 41
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17401-1254
Mailing Address - Country:US
Mailing Address - Phone:717-747-1942
Mailing Address - Fax:
Practice Address - Street 1:1230 GREENSPRINGS DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8825
Practice Address - Country:US
Practice Address - Phone:717-327-8708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier