Provider Demographics
NPI:1669778916
Name:SURVIVOR GALS SPECIALTY PRODUCTS AND SALON LLC
Entity type:Organization
Organization Name:SURVIVOR GALS SPECIALTY PRODUCTS AND SALON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-599-7677
Mailing Address - Street 1:3000 CUSTER RD STE 190
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-2082
Mailing Address - Country:US
Mailing Address - Phone:972-599-7677
Mailing Address - Fax:972-599-1011
Practice Address - Street 1:1400 8TH AVE STE 100-A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-924-8800
Practice Address - Fax:817-924-5500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURVIVOR GALS SPECIALTY PRODUCTSAND SALON LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-03
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier