=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265861405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANE EVENT SALON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2013
-----------------------------------------------------
Last Update Date | 11/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5525 SAINT ELMO AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37409-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-468-3425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5525 SAINT ELMO AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37409-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-468-3425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED HAIR LOSS SPECIALIST
-----------------------------------------------------
Name | EUGENIA E JOHNSON
-----------------------------------------------------
Credential | CERTIFIEDHAIRLOSSSPE
-----------------------------------------------------
Telephone | 423-468-3425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------