Provider Demographics
NPI:1932897113
Name:ENCHANTED ESSENCE BEAUTY BOUTIQUE LLC
Entity Type:Organization
Organization Name:ENCHANTED ESSENCE BEAUTY BOUTIQUE LLC
Other - Org Name:ENCHANTED ESSENCE BEAUTY BOUTIQUE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-770-8023
Mailing Address - Street 1:3710 GRANT DR STE A
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5317
Mailing Address - Country:US
Mailing Address - Phone:775-786-0884
Mailing Address - Fax:775-600-4961
Practice Address - Street 1:3710 GRANT DR STE A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-5317
Practice Address - Country:US
Practice Address - Phone:775-786-0884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-26
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service