Provider Demographics
NPI:1073239265
Name:IAN BRADLEY HAIR SALON LLC
Entity Type:Organization
Organization Name:IAN BRADLEY HAIR SALON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-714-4302
Mailing Address - Street 1:222 JOYCLIFF CIR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-7040
Mailing Address - Country:US
Mailing Address - Phone:478-714-4302
Mailing Address - Fax:478-210-5078
Practice Address - Street 1:3902 NORTHSIDE DR STE A3
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2459
Practice Address - Country:US
Practice Address - Phone:478-845-1210
Practice Address - Fax:478-210-5078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier