Provider Demographics
NPI:1891230744
Name:PRIMA DONNA SALON
Entity Type:Organization
Organization Name:PRIMA DONNA SALON
Other - Org Name:PAYNE'S COSMETOLOGIC INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHAUNA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-580-2584
Mailing Address - Street 1:333 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-4101
Mailing Address - Country:US
Mailing Address - Phone:618-580-2584
Mailing Address - Fax:618-277-0639
Practice Address - Street 1:333 LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-4101
Practice Address - Country:US
Practice Address - Phone:618-580-2584
Practice Address - Fax:618-277-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011307091332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier