Provider Demographics
NPI:1457926164
Name:PHATS EXTENSION BAR & MAKEUP STUDIO LLC
Entity Type:Organization
Organization Name:PHATS EXTENSION BAR & MAKEUP STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR LOSS PRACTTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:SHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:HLP
Authorized Official - Phone:903-722-0734
Mailing Address - Street 1:1950 N NORTHWEST LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-1626
Mailing Address - Country:US
Mailing Address - Phone:903-747-8060
Mailing Address - Fax:
Practice Address - Street 1:1950 N NORTHWEST LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-1626
Practice Address - Country:US
Practice Address - Phone:903-747-8060
Practice Address - Fax:903-747-8060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment