Provider Demographics
NPI:1023543048
Name:5TH AVENUE GROOMING LOUNGE
Entity type:Organization
Organization Name:5TH AVENUE GROOMING LOUNGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAREESHIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-899-3054
Mailing Address - Street 1:1201 N WATSON RD
Mailing Address - Street 2:STE 283
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-6190
Mailing Address - Country:US
Mailing Address - Phone:817-899-3054
Mailing Address - Fax:
Practice Address - Street 1:1201 N WATSON RD.
Practice Address - Street 2:SUITE 283
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76116
Practice Address - Country:US
Practice Address - Phone:817-899-3054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226797335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier