Healthcare Provider Details

I. General information

NPI: 1174427637
Provider Name (Legal Business Name): SALON SA- TREICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 W US HIGHWAY 50
FAIRVIEW HEIGHTS IL
62208-2927
US

IV. Provider business mailing address

1923 W US HIGHWAY 50
FAIRVIEW HEIGHTS IL
62208-2927
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-9499
  • Fax:
Mailing address:
  • Phone: 618-628-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: SAMANTHA BROWN
Title or Position: OWNER
Credential: MPC
Phone: 618-628-9499