Provider Demographics
NPI:1063117810
Name:FOREVER DIAZ SALON & SPA, LLC
Entity type:Organization
Organization Name:FOREVER DIAZ SALON & SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-854-3307
Mailing Address - Street 1:8237 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2865
Mailing Address - Country:US
Mailing Address - Phone:410-497-0782
Mailing Address - Fax:
Practice Address - Street 1:8237 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2865
Practice Address - Country:US
Practice Address - Phone:410-497-0782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment