Provider Demographics
NPI:1700426137
Name:FACESOFEXOTICISM
Entity Type:Organization
Organization Name:FACESOFEXOTICISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOSHELL
Authorized Official - Middle Name:ABRIANA
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-983-3815
Mailing Address - Street 1:22 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-4117
Mailing Address - Country:US
Mailing Address - Phone:516-983-3815
Mailing Address - Fax:
Practice Address - Street 1:22 ROBINSON DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-4117
Practice Address - Country:US
Practice Address - Phone:516-983-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY263113304Medicaid