Provider Demographics
NPI:1629603741
Name:MANE OF YOUR DREAM
Entity Type:Organization
Organization Name:MANE OF YOUR DREAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CRENDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-437-2272
Mailing Address - Street 1:10210 BASELINE RD SPC 267
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-6048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11553 FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0731
Practice Address - Country:US
Practice Address - Phone:909-969-1833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAKK347413OtherCOSMETOLOGY LICENSE