Provider Demographics
NPI:1639352180
Name:BEAUTIFUL ME
Entity Type:Organization
Organization Name:BEAUTIFUL ME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-723-5555
Mailing Address - Street 1:531 VALLEY VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125
Mailing Address - Country:US
Mailing Address - Phone:262-275-5000
Mailing Address - Fax:
Practice Address - Street 1:531 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:WI
Practice Address - Zip Code:53125-1198
Practice Address - Country:US
Practice Address - Phone:262-275-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI004-0002290200-01335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier