Provider Demographics
NPI:1750050647
Name:AMT SALON AND HAIR REPLACEMENT CENTER LLC
Entity Type:Organization
Organization Name:AMT SALON AND HAIR REPLACEMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TABB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-456-0219
Mailing Address - Street 1:4039 E KIEHL AVE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3514
Mailing Address - Country:US
Mailing Address - Phone:870-456-0219
Mailing Address - Fax:501-285-8949
Practice Address - Street 1:4039 E KIEHL AVE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-3514
Practice Address - Country:US
Practice Address - Phone:870-456-0219
Practice Address - Fax:501-285-8949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA