Provider Demographics
NPI:1548790298
Name:FRESH HEADS LICE REMOVAL
Entity Type:Organization
Organization Name:FRESH HEADS LICE REMOVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:L
Authorized Official - Last Name:OTTESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-686-4175
Mailing Address - Street 1:653 LAKE STONE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4342
Mailing Address - Country:US
Mailing Address - Phone:904-235-3157
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 1801
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5227
Practice Address - Country:US
Practice Address - Phone:904-517-4087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty