Provider Demographics
NPI:1669732301
Name:MULBERRY WELLNESS SALON LLC
Entity type:Organization
Organization Name:MULBERRY WELLNESS SALON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASTER COSMETOLOGIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED HAIR LOSS
Authorized Official - Phone:334-868-5189
Mailing Address - Street 1:1734 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1524
Mailing Address - Country:US
Mailing Address - Phone:334-819-7249
Mailing Address - Fax:334-819-7249
Practice Address - Street 1:1734 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1524
Practice Address - Country:US
Practice Address - Phone:334-819-7249
Practice Address - Fax:334-819-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL161733174400000X, 332BC3200X
AL390891744P3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL39089OtherMASTER COSMETOLOGIST; NON-SURGICAL HAIR REPLACEMENT