Healthcare Provider Details

I. General information

NPI: 1649261249
Provider Name (Legal Business Name): FIRM FOUNDATIONS SALON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1566 DIEDERICH BLVD
RUSSELL KY
41169-1676
US

IV. Provider business mailing address

1566 DIEDERICH BLVD
RUSSELL KY
41169-1676
US

V. Phone/Fax

Practice location:
  • Phone: 606-834-1040
  • Fax: 606-834-1044
Mailing address:
  • Phone: 606-834-1040
  • Fax: 606-834-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number149620
License Number StateKY

VIII. Authorized Official

Name: MRS. DEIRDRE B BRADLEY
Title or Position: OWNER/FITTER
Credential: CFM
Phone: 606-834-1040