Provider Demographics
NPI:1396335006
Name:BEAUTIQUE EXTENSION
Entity type:Organization
Organization Name:BEAUTIQUE EXTENSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TY-ESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-399-3545
Mailing Address - Street 1:208 STAFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-3311
Mailing Address - Country:US
Mailing Address - Phone:315-399-3545
Mailing Address - Fax:
Practice Address - Street 1:208 STAFFORD AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-3311
Practice Address - Country:US
Practice Address - Phone:315-399-3545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier