Provider Demographics
NPI:1821464322
Name:PURPLE PALACE
Entity Type:Organization
Organization Name:PURPLE PALACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:234-521-9147
Mailing Address - Street 1:1214 MILFORD ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-1636
Mailing Address - Country:US
Mailing Address - Phone:234-521-9147
Mailing Address - Fax:
Practice Address - Street 1:1214 MILFORD ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-1636
Practice Address - Country:US
Practice Address - Phone:234-521-9147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOSM.9338951744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1744P32OOXOtherCERTIFIED HAIR LOSS SPECIALIST