Provider Demographics
NPI:1134748767
Name:THE WEAVE LUXE BAR
Entity type:Organization
Organization Name:THE WEAVE LUXE BAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAYLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-506-1551
Mailing Address - Street 1:7315 LEMONT RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3807
Mailing Address - Country:US
Mailing Address - Phone:630-506-1551
Mailing Address - Fax:252-650-6564
Practice Address - Street 1:7315 LEMONT RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3807
Practice Address - Country:US
Practice Address - Phone:630-506-1551
Practice Address - Fax:252-650-6564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier