Provider Demographics
NPI:1568871200
Name:PHYLLIS DAVIS COSMETOLOGIST
Entity Type:Organization
Organization Name:PHYLLIS DAVIS COSMETOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COSMETOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:TERRI
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-728-0045
Mailing Address - Street 1:6057 TWYCKENHAM DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-7372
Mailing Address - Country:US
Mailing Address - Phone:317-728-0045
Mailing Address - Fax:
Practice Address - Street 1:2336 E 53RD ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3430
Practice Address - Country:US
Practice Address - Phone:317-259-2957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INBC107209275335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier