Provider Demographics
NPI:1538621107
Name:GENRICH, CYNTHIA (COSMETOLOGIST)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:GENRICH
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7937 INGRAM RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4710
Mailing Address - Country:US
Mailing Address - Phone:815-222-5187
Mailing Address - Fax:
Practice Address - Street 1:421 S MULFORD RD STE 203
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3010
Practice Address - Country:US
Practice Address - Phone:815-222-5187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011.148061246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL011.148061OtherCOSMETOLOGIST