Provider Demographics
NPI:1972015105
Name:BEAUTICIANS ON THE GO, PLLC
Entity type:Organization
Organization Name:BEAUTICIANS ON THE GO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:OLIVARES
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLOGIST
Authorized Official - Phone:602-803-2827
Mailing Address - Street 1:PO BOX 74322
Mailing Address - Street 2:
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-1006
Mailing Address - Country:US
Mailing Address - Phone:602-803-2728
Mailing Address - Fax:602-218-4498
Practice Address - Street 1:2390 E CAMELBACK RD STE 130
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3449
Practice Address - Country:US
Practice Address - Phone:602-803-2827
Practice Address - Fax:602-218-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10223435251E00000X, 253Z00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1972015105OtherNON- MEDICARE
AZ1972015105Medicaid