Provider Demographics
NPI:1659664407
Name:HEAVEN ON EARTH SALON LLC
Entity Type:Organization
Organization Name:HEAVEN ON EARTH SALON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIC SPECIALIST /COSM.
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:SPECIALIST
Authorized Official - Phone:419-917-1268
Mailing Address - Street 1:1612 W SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1589
Mailing Address - Country:US
Mailing Address - Phone:419-917-1268
Mailing Address - Fax:
Practice Address - Street 1:1612 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1589
Practice Address - Country:US
Practice Address - Phone:419-917-1268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH953162335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier