Provider Demographics
NPI:1326781485
Name:GLAMOROUS LYFE DIVAZ LLC
Entity Type:Organization
Organization Name:GLAMOROUS LYFE DIVAZ LLC
Other - Org Name:GLAMOROUS LYFE DIVAZ
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-702-8141
Mailing Address - Street 1:1548 WHITEFRIAR DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-5109
Mailing Address - Country:US
Mailing Address - Phone:352-702-8141
Mailing Address - Fax:
Practice Address - Street 1:800 PLEASANTDALE DR
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3527
Practice Address - Country:US
Practice Address - Phone:352-702-8141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment