Provider Demographics
NPI:1972330017
Name:BEAUTY & WELLNESS BOUTIQ
Entity type:Organization
Organization Name:BEAUTY & WELLNESS BOUTIQ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-409-6931
Mailing Address - Street 1:4578 N BISCAYNE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34291-7081
Mailing Address - Country:US
Mailing Address - Phone:813-409-6931
Mailing Address - Fax:
Practice Address - Street 1:14846 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2701
Practice Address - Country:US
Practice Address - Phone:813-409-6931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty