Provider Demographics
NPI:1154020865
Name:MODISH BEAUTE LLC
Entity type:Organization
Organization Name:MODISH BEAUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-863-2589
Mailing Address - Street 1:532 MOLINE WAY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4471
Mailing Address - Country:US
Mailing Address - Phone:321-863-2589
Mailing Address - Fax:321-406-1325
Practice Address - Street 1:532 MOLINE WAY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-4471
Practice Address - Country:US
Practice Address - Phone:321-863-2589
Practice Address - Fax:321-406-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier