1679235303 NPI number — SALON ONE TWENTY FOUR L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679235303 NPI number — SALON ONE TWENTY FOUR L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALON ONE TWENTY FOUR L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679235303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 444
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71711-0444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-454-7017
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 E WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71701-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-454-7017
Provider Business Practice Location Address Fax Number:
501-830-4033
Provider Enumeration Date:
10/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
LAVON
Authorized Official Middle Name:
CHERALE
Authorized Official Title or Position:
CRANIAL PROSTHETIC SPECIALIST
Authorized Official Telephone Number:
870-675-1246

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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