Provider Demographics
NPI:1598526931
Name:MIRROR GAZE BEAUTY BAR LLC
Entity Type:Organization
Organization Name:MIRROR GAZE BEAUTY BAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR REPLACEMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-750-9290
Mailing Address - Street 1:5432 VIEWMONT DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-1705
Mailing Address - Country:US
Mailing Address - Phone:470-430-2949
Mailing Address - Fax:
Practice Address - Street 1:6631B OLD STATESVILLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1733
Practice Address - Country:US
Practice Address - Phone:704-750-9290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment