Provider Demographics
NPI:1760852206
Name:HAIR CLINIQUE SALON
Entity Type:Organization
Organization Name:HAIR CLINIQUE SALON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:LINDSAY
Authorized Official - Last Name:MOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-912-4661
Mailing Address - Street 1:3500 GWINNETT PLACE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4700
Mailing Address - Country:US
Mailing Address - Phone:770-912-4661
Mailing Address - Fax:
Practice Address - Street 1:3500 GWINNETT PLACE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4700
Practice Address - Country:US
Practice Address - Phone:770-912-4661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-27
Last Update Date:2015-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1002231744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty