Provider Demographics
NPI:1013669142
Name:BUNNI MICHELLES SALON & BEAUTY BOUTIQUE LLC
Entity Type:Organization
Organization Name:BUNNI MICHELLES SALON & BEAUTY BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-221-0616
Mailing Address - Street 1:3500 VIRGINIA BEACH BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4445
Mailing Address - Country:US
Mailing Address - Phone:872-221-0616
Mailing Address - Fax:888-474-7750
Practice Address - Street 1:3500 VIRGINIA BEACH BLVD STE 208
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4445
Practice Address - Country:US
Practice Address - Phone:872-221-0616
Practice Address - Fax:888-474-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier