Provider Demographics
NPI:1700210689
Name:EDGE LUXE IMAGE CONSULTING LLC
Entity Type:Organization
Organization Name:EDGE LUXE IMAGE CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDI
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BOZEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-241-2972
Mailing Address - Street 1:112 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-1370
Practice Address - Country:US
Practice Address - Phone:937-241-2972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier