Provider Demographics
NPI:1902399942
Name:DIVINE BEAUTY BAR, LLC
Entity Type:Organization
Organization Name:DIVINE BEAUTY BAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEZAREE'
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSK
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:469-499-6200
Mailing Address - Street 1:4201 CYPRESS CREEK PKWY STE 322
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77068-3414
Mailing Address - Country:US
Mailing Address - Phone:469-499-6200
Mailing Address - Fax:469-519-5839
Practice Address - Street 1:4201 CYPRESS CREEK PKWY STE 322
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77068-3414
Practice Address - Country:US
Practice Address - Phone:469-499-6200
Practice Address - Fax:469-519-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14495351744P3200X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1449535OtherTEXAS DEPARTMENT OF LICENSING AND REGISTRATION
TXC53480OtherCERTIFIED MASTECTOMY FITTER