Provider Demographics
NPI:1912383605
Name:RAW ELEGANCE HAIR SOLUTIONS
Entity Type:Organization
Organization Name:RAW ELEGANCE HAIR SOLUTIONS
Other - Org Name:HOUSE OF RAW ELEGANCE HAIR SOLUTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:314-299-8926
Mailing Address - Street 1:2955 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1415
Mailing Address - Country:US
Mailing Address - Phone:314-299-8926
Mailing Address - Fax:
Practice Address - Street 1:2955 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1415
Practice Address - Country:US
Practice Address - Phone:314-299-8926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140119671744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty