Provider Demographics
NPI:1699016279
Name:PAMELA RENE LUXURIOUS HAIR SALON
Entity Type:Organization
Organization Name:PAMELA RENE LUXURIOUS HAIR SALON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER COSMETOLOGIST
Authorized Official - Phone:404-831-8521
Mailing Address - Street 1:1151 HAMMOND DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346
Mailing Address - Country:US
Mailing Address - Phone:404-831-8521
Mailing Address - Fax:
Practice Address - Street 1:1151 HAMMOND DR NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-1524
Practice Address - Country:US
Practice Address - Phone:404-831-8521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACASA048619305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service