Provider Demographics
NPI:1609658996
Name:REVIVE HAIR & NAIL SOLUTIONS LLC
Entity Type:Organization
Organization Name:REVIVE HAIR & NAIL SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CORNELIA
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:234-804-1515
Mailing Address - Street 1:2219 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2736
Mailing Address - Country:US
Mailing Address - Phone:234-804-1515
Mailing Address - Fax:
Practice Address - Street 1:2219 34TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2736
Practice Address - Country:US
Practice Address - Phone:123-480-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH19320000XOtherMULTI SPECIALTY GROUP
OH335E00000XOtherORTHOTIC SUPPLIER
OH1744P3200XOtherPROSTHETICS CASE MANAGER
OH332B00000XOtherMEDICAL EQUIPMENT AND MEDICAL SUPPLIES