Provider Demographics
NPI:1912537705
Name:THE W BEAUTY AND BARBER LOUNGE
Entity Type:Organization
Organization Name:THE W BEAUTY AND BARBER LOUNGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED COSMETOLOGISTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:EPIPHANY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-213-7443
Mailing Address - Street 1:18718 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2215
Mailing Address - Country:US
Mailing Address - Phone:313-340-2834
Mailing Address - Fax:
Practice Address - Street 1:18718 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2215
Practice Address - Country:US
Practice Address - Phone:313-340-2834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier