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General NPI Number Information
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NPI Number | 1760852206
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Entity Type | Organization
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Legal Business Name | HAIR CLINIQUE SALON
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Dates
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Enumeration Date | 09/27/2015
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Last Update Date | 09/27/2015
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Provider Practice Location Address
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Address Line | 3500 GWINNETT PLACE DR SUITE 5
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City | DULUTH
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State | GA
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Zip | 30096-4700
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Country | US
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Telephone | 770-912-4661
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Fax |
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Provider Business Mailing Address
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Address Line | 3500 GWINNETT PLACE DR SUITE 5
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City | DULUTH
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State | GA
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Zip | 30096-4700
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Country | US
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Telephone | 770-912-4661
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DIONNE LINDSAY MOLDEN
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Credential |
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Telephone | 770-912-4661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1744P3200X
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Taxonomy Name | Prosthetics Case Management
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License Number | CO100223
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License Number State | GA
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