Healthcare Provider Details

I. General information

NPI: 1558813295
Provider Name (Legal Business Name): SALON LYON , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 WEST AVE, SE B
CONYERS GA
30012
US

IV. Provider business mailing address

1112 WEST AVE. SE SUITE B
CONYERS GA
30012
US

V. Phone/Fax

Practice location:
  • Phone: 770-648-6187
  • Fax:
Mailing address:
  • Phone: 770-648-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCO089141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO089141
License Number StateGA

VIII. Authorized Official

Name: MRS. ROBIN LENETTE LYONS
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: CHS
Phone: 770-648-6187