Healthcare Provider Details

I. General information

NPI: 1073239265
Provider Name (Legal Business Name): IAN BRADLEY HAIR SALON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 NORTHSIDE DR STE A3
MACON GA
31210-2459
US

IV. Provider business mailing address

222 JOYCLIFF CIR
MACON GA
31211-7040
US

V. Phone/Fax

Practice location:
  • Phone: 478-845-1210
  • Fax: 478-210-5078
Mailing address:
  • Phone: 478-714-4302
  • Fax: 478-210-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MELISSA R MCCOY
Title or Position: OWNER
Credential:
Phone: 478-714-4302