Provider Demographics
NPI:1609409523
Name:MISS ALTER EGO SALON, LLC
Entity Type:Organization
Organization Name:MISS ALTER EGO SALON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:KLOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-206-9472
Mailing Address - Street 1:21185 NW WEST UNION RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-8543
Mailing Address - Country:US
Mailing Address - Phone:503-206-9472
Mailing Address - Fax:
Practice Address - Street 1:21185 NW WEST UNION RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-8543
Practice Address - Country:US
Practice Address - Phone:503-206-9472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Single Specialty