MEDICARE: INDEPENDENT SALON GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)	CO087243	GA

General Provider Information

NPI Number	:	1801163019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT SALON GROUP INC

Provider Business Mailing Address
First Line	:	4830 STEEPLECHASE COURT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127
Country	:	US
Telephone Number	:	678-401-0366
Fax Number	:

Provider Business Practice Location Address
First Line	:	4830 STEEPLECHASE CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2567
Country	:	US
Telephone Number	:	678-401-0366
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. ALTALISIA D HARALSON
Credential	:
Telephone Number	:	678-491-0110

Provider Enumeration Date	:	11/17/2011
Last Update Date	:	11/17/2011

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