Healthcare Provider Details

I. General information

NPI: 1194350397
Provider Name (Legal Business Name): SALON ELEGANCE HAIR STUDIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 POWDER SPRINGS RD SW
MARIETTA GA
30064-4567
US

IV. Provider business mailing address

2365 POWDER SPRINGS RD SW
MARIETTA GA
30064-4567
US

V. Phone/Fax

Practice location:
  • Phone: 770-420-8110
  • Fax:
Mailing address:
  • Phone: 770-420-8110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: NICOLE FERGUSON
Title or Position: CEO
Credential:
Phone: 770-420-8110