Provider Demographics
NPI:1902546187
Name:DIVINE LASH & BEAUTY BAR
Entity Type:Organization
Organization Name:DIVINE LASH & BEAUTY BAR
Other - Org Name:DIVINE LUXURY BUNDLES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/AESTTHETICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-202-6350
Mailing Address - Street 1:10520 N BAEHR RD STE M
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-6701
Mailing Address - Country:US
Mailing Address - Phone:262-417-8385
Mailing Address - Fax:414-202-6350
Practice Address - Street 1:10520 N BAEHR RD STE M
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-6701
Practice Address - Country:US
Practice Address - Phone:262-417-8385
Practice Address - Fax:414-202-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier