Healthcare Provider Details

I. General information

NPI: 1174028229
Provider Name (Legal Business Name): LYLA TERRY SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12559 FALLOHIDE LN
JACKSONVILLE FL
32225-3457
US

IV. Provider business mailing address

12559 FALLOHIDE LN
JACKSONVILLE FL
32225-3457
US

V. Phone/Fax

Practice location:
  • Phone: 904-487-8468
  • Fax:
Mailing address:
  • Phone: 904-487-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: SCHQUANDA TERRY
Title or Position: SPECIALIST
Credential:
Phone: 904-487-8468