Provider Demographics
NPI:1255175311
Name:CAESAR, MARILYN (COSMETOLOGIST)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CAESAR
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 ACORN FOREST LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1732
Mailing Address - Country:US
Mailing Address - Phone:980-275-9466
Mailing Address - Fax:
Practice Address - Street 1:650 E BROOKLYN VILLAGE AVE STE 22
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-3400
Practice Address - Country:US
Practice Address - Phone:980-275-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier